THE  LIBRARY 

OF 

THE  UNIVERSITY 
OF  CALIFORNIA 

LOS  ANGELES 


, 

S  ANGELES .CAUF. 


Short  Zlalfcs 
Mitb  lacuna  Mothers 

ON  THE  MANAGEMENT  OF  INFANTS 
AND  YOUNG  CHILDREN 


CHARLES  GILMORE  KERLEY,  M.D. 

Professor  of  Diseases  of  Children,  New  York  Polyclinic  Medical  Schooj 

and  Hospital ;  Attending  Physician  to  the  New  York  Infant  Asylum  ; 

Assistant    Attending   Physician   to   the   Babies'    Hospital,   New 

York  ;  Consulting  Physician,  New   York  Home  for  Crippled 

and  Destitute  Children;  Consulting  Pediatrist,  Greenwich 

Hospital;  Consulting  Physician,  Savilla  Home,  N.  Y. 


Z  /  3*26 

SECOND  EDITION i  REl'ISED  AND  ENLARGED 
ILLUSTRATED 


G.  P.  PUTNAM'S  SONS 
NEW  YORK  &  LONDON 
Cbe  •fcntcfccrbocKcr  press 


COPYRIGHT,  igot 

H  \ 
CHARLES  (ill.MORE   KERLEY 

Coi'VKICIM  I  ,    igOQ 
BY 

CHARLES  (HLMORE   KERLEY 

(K..r  Revised  Edition) 


7  (  :  r,  •  , 


"Cbc  *n(cfcerbc>cfe«r  frete,  tAew 


M 


TO 
L.  EMMETT  HOLT,  M.D. 

Clinical  Professor  of  Diseases  of  Children  in  the  College  of  Physician* 
and  Surgeons  (Columbia  University)  New  York 

THIS  WORK  IS  INSCRIBED 

IN  RECOGNITION  OF    HIS  HIGH   PROFESSIONAL  ATTAINMENTS    AND 

ENTHUSIASM     IN     PROMOTING     THE     STUDY     OF     DISEASES 

OF     CHILDREN,     AND     IN     GRATEFUL     APPRECIATION 

OF    MANY     ACTS     OF     KINDNESS 


PREFACE  TO  SECOND  EDITION 

THIS  book  was  originally  prepared  with  the 
view  of  aiding  young  mothers  in  the  care 
and  rearing  of  their  children.  In  the  second 
edition,  new  subject  matter  has  been  added,  to- 
gether with  additions  to  the  text,  with  the 
hope  of  further  extending  its  field  of  usefulness. 


PREFACE 

THE  aim  of  this  book  is  to  help  the 
young  mother  to  a  closer  acquaint- 
ance with  and  a  more  intelligent  apprecia- 
tion of  the  nature  and  demands  of  the 
little  life  entrusted  to  her  care. 

In  its  preparation  the  author  has  kept 
in  mind  and  has  endeavored  to  answer 
the  personal  questions  of  many  thought- 
ful young  mothers.  The  better-class  young 
mother  of  the  present  day  is  not  content 
with  the  meagre  information  possessed  by 
her  mother  and  grandmother. 

Suggestions  relating  to  medical  treat- 
ment are  intentionally  avoided.  A  mother 
should  know  all  the  details  of  the  child's 
feeding,  clothing,  bathing,  and  airing,  and 
what  to  do  in  an  emergency.  She  should 
also  be  able  to  recognize  symptoms  of 
illness  and  appreciate  their  significance. 
She  is  not  supposed  to  be  skilled  in  the 
use  of  drues. 


INDEX 

PAGB 

Adenoids       .          .          .          .  .  137 

Appetite        .          .          .          .  .  .143 

Artificial — -bottle — feeding       .  .  .54 

Preparation  of  food            .  .  -59 

Milk  and  cream  feeding    .  .  .61 
Top-milk  feeding     ....        65 

Baskets  for  early  exercise         .  .  .     316 

Baths  .          .          .          .          .  .  .117 

The  cold  douche       .          .  .  .118 

Tub-baths  for  fever           .  .  .120 

Basin  bathing  for  fever     .  .  .120 
Bathing  for  comfort  in  hot  weather   .      120 

Mustard  bath            .          .  .  .121 

Brine  bath       .           .          .  .  .121 

Soda  bath        .          .          .  .  .121 

Bran  bath        .          .          .  .  .122 

Starch  bath     .          .          .  .  .122 

Hot  bath          .          .          .  .  .122 

Bed-wetting            .          .          .  .  .284 

Bites  of  animals     .          .          .  .  .248 

Bites  of  insects       .          .          .  .  .248 

Boils     .          .          .          .          .  .  .245 

Bronchitis      .           .           .           .  .  .171 

Burns  ......      246 


x  Index 

PACK 

Care  of  the  breasts  and  nipples         .          .       45 
Care  of  the  genitals         .          .          .          .287 

Painful  micturition,  circumcision        .      287 
Chicken-pox  .          .          .          .          .194 

Children's  parties  .          .          .          -315 

Cleanliness     ......      303 

Clothing  to  be  provided  ...          3 

Cold  hands  and  feet         .          .          .          .304 

Cold  in  the  head  (coryza)         .          .          .169 
Colic     .          .          .          .          .  .          .269 

Condensed  milk      .....        86 

Constipation.          .          .          .          .          .274 

Management  in  the  breast-fed  .  .275 

Management  in  the  bottle-fed   .          .277 

Management  in  older  children   .          .279 

Convulsions  .          .          .          .          .          .265 

Cough  .          .          .          .          .  .          -163 

Chronic  cough  .          .          .  .164 

Croup — catarrhal,  diphtheritic          .          .      173 

Crying  •      302 

Cuts,  bruises,  and  sprains         .          .          .295 

Dangers  from  flies  and  mosquitoes   .  -307 

Dentition       .           .           .           .           .  .126 

The  breast-fed           .           .           .  .126 

The  well-managed  bottle-fed      .  .      127 

The  badly  fed            .            .           .  .127 

Diet  after  the  sixth  year  ...        83 

Diet  during  illness            .           .           .  .      101 

The  art  of  feeding  in  illness        .  .      103 


Index  xi 

PAOK 

Disinfection    after   contagious   diseases  — 

fumigation  .          .          .          .          .201 

Diphtheria    .          .          .          .          .          .191 

Drug-giving 312 

Earache         .          .  .  .  .  .122 

Eczema          .          .  .  .  .  .2.31 

The  strait- jacket  .  .  .  -233 

The  mask        .  .  .  .  .235 

Enlarged  tonsils     .  .  .  .  .140 

Excitement  .          .  .  .  .  .296 

Feeding  after  the  first  year      .          .          -73 
Fever   .......      249 

Fissures  of  the  anus         ....      244 

Food  formulas        .          .          .          .          .324 

Beef-juice        .  .          .          .          .324 

Beef,  mutton,  and  chicken  broth          .      325 
Scraped  beef  .          .          .          .  325 

Egg- water 325 

Oatmeal  jelly  .          .          .  .325 

Wheat  jelly  and  barley  jelly      .          .      325 
Barley-water  .          .          .          .          .326 

Rice-water       .          .          .          .          .326 

Dextrinized  barley-water  .          .      326 

Oatmeal-water          .          .          .          .326 

Imperial  granum-water     .          .          .326 
Whey     .          .          .          .          .          .326 

Junket  .          .          .          .          .327 

Foreign  bodies  in  the  <?;ir  and  nose    .  .306 


xii  Index 

PAGE 

Foreign  bodies  swallowed         .          .          .305 

German  measles     .          .          .          .          .185 

Glands.          .          .          .          .          .          .228 

Acute  enlargement  of  the  glands  of  the 
neck   ......      228 

Chronic  enlargement  of  the  glands  of 
the  neck      .          .          .          .          .229 

Grippe  ......     262 

Habits  .          .          .          .          .          -147 

Ear-pulling     .          .          .          .          .150 

The  "pacifier"  habit         .          .          .148 
Masturbation  .          .          .          .          -150 

Habitual  vomiting  ....      106 

Head  lice — pediculi  capitis       .          .          .247 
Height  in  inches  from  birth  to  sixth  year   .          9 
Hives   .          .          .          .          .          .          .237 

How  the  child  should  be  fed  ...  84 
How  to  examine  the  throat  .  .  .153 
How  to  lift  the  baby  ....  9 

Indoor  airing  .....      314 

Intertrigo      ......      239 

Kissing  ......      297 

Malaria          .          .          .          .          .          .251 

Malnutrition  and  marasmus  .  .  .  107 
Maternal  nursing  .  .  .  .  .13 

The  diet 21 

The  bowel  function  ...        23 


Index  xiii 

PACE 

Maternal  Nursing — Continued 

Air  and  exercise       ....        24 

Regularity  in  nursing        .          .          .25 
Signs  of  successful  nursing         .          .        26 
Signs  of  unsuccessful  nursing     .          .        27 
Signs  of  insufficient  nursing       .          .        32 
Management  of  abnormal  milk  condi- 
tions .          .          .          .  .32 

Mixed  feeding  .  .          .  -35 

Maternal  conditions  under  which  nurs- 
ing is  forbidden    ....        36 

Conditions    which    may    temporarily 

produce  an  unfavorable  effect  upon 

the  breast-milk,  but  not  necessitate 

the  discontinuance  of  nursing          .        36 

Conditions  which  call  for  temporary 

discontinuance  of  nursing        .  .        38 

Care  of  the  nipples  .          .  .  -        39 

Giving  of  water         ....        40 

Frequency  of  nursings       ...        40 
Measles  .          .          .          .          .          .195 

Milk-crust      .          .          .          .          .          .238 

Milk  for  travelling.  .  .  .  .99 

Milk  in  infants'  breasts  .  .  .141 

Mumps  .  .  .  .  .  .186 

Night  terrors  .          .          .          .  .318 

Nose-bleed     .  .  .  .  .  .291 

Nursery-maids        .  .  .  .  .134 

Patent  medicines    .  .  .  .  .309 


xiv  Index 

PAGB 

Peptonized  milk     .          .          .          .  -95 

Immediate  process  .          .          .  .97 

Cold  process    .....       98 

Partially  peptonized  milk           .  .        98 

Completely  peptonized  milk       .  .        99 

Pneumonia    .          .          .          .          .  .177 

Premature  and  congenitally  weak  infants       222 

Prickly  heat            .          .          .          .  .241 

Retention  of  urine            .           .          .  .289 

Rheumatism            .           .          .           .  .261 

Rickets           .          .          .           .           .  .256 

Scales  for  weighing          .          .          .  .319 

Scarlet  fever.           .           .           .          .  .182 

Scurvy            .           .           .           .           .  .259 

Sick-room  for  contagious  diseases — -qua- 
rantine     .           .           .           .  .198 

Disinfectant  drugs   .  .      200 

Sleep    ...  .      299 

Sprue  and  thrush  .      154 

Sterilization  and  pasteurization  of  milk  .        71 

Stomatitis,  or  sore  mruth         .           .  .157 

Summer  diarrhoea            .  .in 

Bowel  irrigation        .           .           .  .115 

Prevention       .           .           .           .  .116 

Reduction  of  food    .           .           .  .116 

Cleanliness       .           .           .           .  .116 

Summer  resorts      .           .          .          .  .310 

Taking  cold  .           .           .           .           .  .159 


Index  xv 

PACK 

Temperature,  and  how  to  take  it  .  .      142 

The  baby-basket  and  its  contents  .  .          i 

The  care  of  the  eyes        .          .  .  .125 

The  contagious  diseases            .  .  .180 

The  daily  outing    .          .          .  .  313 

The  delicate  child            .          .  .  -203 

Normal  development         .  .  .204 

Abnormal  development     .  .  .      204 

Management   .           .           .  .  .205 

Regular  weighings  necessary  .  .207 

Feeding  delicate  infants    .  .  .208 

Diet  after  the  first  year    .  .  .211 

Baths     .           .          .          .  .  .213 

Fresh  air          .          .          .  .  .214 

Sleep      .          .          .          .  .  .216 

The  nursery    .           .          .  .  .216 

Influence  of  climate            .  .  .218 

Clothing           .          .          .  .  .219 

As  to  the  nature  of  the  clothing  .      219 

Exercise           .          .          .  .  .220 

Midday  nap     .           .           .  .  .220 

Entertainment          .           .  .  .220 

Education        .          .          .  .  .221 

The  exercise  pen    .          .          .  .  .321 

The  first  duty  to  the  child        ...          3 
The  hair         ......      133 

The  normal  throat           .          .  .  .152 

The  nursery  .           .           .           .  .  .10 

The  nursing-bottle  and  nipple  .  .        53 


xvi  Index 

PAGS 

The  proprietary  foods     ....       90 

The  uses    of    proprietary    dried-milk 
foods  .          .          .          .          .          .92 

Proprietary  foods  to  which  fresh  cows' 
milk  is  added        .          .          .          .93 

The  proprietary  beef  foods         .          .       94 
The  selection  of  milk      ....        50 

The  skin  in  health  .          .          .          .230 

The  teeth 130 

The  care  of  the  teeth         .          .          -131 

The  permanent  teeth         .          .          .132 

The  trained  nurse  .          .          .  1 3  5 

The  weight  of  the  well  baby    ...          7 

The  well  baby 5 

The  wet-nurse        .          .          .          .          .41 

Tonsillitis 168 

Tuberculosis  .          .          .          .          -253 

Vaccination  .          .          .          .          .          .282 

Vomiting       .          .          .          .          .          .105 

Weaning        ......       48 

Care  of  breasts  during  weaning  .  49 

When  to  send  for  the  doctor   .          .  .308 

Worms           .          .          .          .          .  .292 

Round -worms           .          .          .  .292 

Thread-worms          .          .          .  .293 

Tape-worms  .  .  .  .  .294 

Whooping-cough    .          .          .          .  .188 


ILLUSTRATIONS 


PAGB 


Baby-Basket  .....          2 

Nipple-Shield  .....  46 
English  Breast-Pump  ....  47 
Nursing  Bottle  and  Nipple  .  .  -  54 
The  Chapin  Dipper  .  .  .  -59 
One  pint  Graduate  ....  60 

Freeman    Pasteurizer    with    Bottle    Rack 

Removed  .          .          .          .          .72 

The  Throat  Examination  .  .  .154 
Cold  Compress  .  .  .  .  .169 
The  Holt  Croup-Kettle  .  .  .  .175 
Crib  Prepared  for  Steam  Inhalation  .  .  176 
The  Electrotherm  .  .  .  .224 

The  Breck  Feeder  .          .          .          .227 

Strait- Jacket  .          .          .          .          .233 

Strait-Jacket  in  Position  .  .  .      234 


xviii  Illustrations 


PAGE 


Mask  Pattern  .  .  .  .  -235 
Hood  in  Position  .  .  .  .  .236 
The  Bulb  Syringe  .  .  .  .281 

Basket  for  Early  Exercise  .  .  -317 
Scoop  and  Platform  Scales  for  Weighing  .  320 
Exercise  Pen  .  .  .  .  .322 


SHORT  TALKS 
WITH  YOUNG  MOTHERS 


THE  BABY-BASKET  AND  ITS  CONTENTS 
2.  /  3  2.  & 
(See  Fig.  i.) 

A  BASKET  in  which  all  the  toilet  necessi- 
ties for  the  baby  may  be  kept  together 
will  be  found  a  great  convenience  when  the 
time  for  their  use  arrives. 

To  be  provided  are: 

A    good-sized    pin-cushion  and  pins. 

Puff-box  and   puff. 

Soap-box  containing  Castile  soap. 

Infant's  hair  brush  and  fine  comb. 

Eight  ounces  of  a  saturated  solution  of 
boracic  acid  for  mouth  and  eyes. 

One-half  pound  of  absorbent  cotton. 

A  package  of  wooden  toothpicks. 

A  bottle  of  white  vaseline. 


The  Baby-Basket 

A  bath  thermometer. 

One  yard  of  plain  sterile  gauze. 

Plenty  of  soft  old  linen. 

Six  of  the  best  baby  towels. 


FIG.     I.       HAHY-BASKKT 


A  white  eiderdown  blanket  one  and  one 
half  yards  l<m,^. 

One  pair  of  small  scissors. 


Clothing  to  be  Provided         3 

A  package  of  nickel-plated  safety-pins 
(three  sizes). 

CLOTHING  TO  BE  PROVIDED 

Forty-eight  cotton  diapers,  made  from 
birdseye  cotton  diaper ;  two  sizes  are  necessary . 

(a)  Three  pieces  20  in. 

(b)  Three  pieces  22  in. 

One  yard  of  white  flannel  for  belly-bands. 
Leave  the  piece  as  it  is,  to  be  used  by  the 
trained  nurse  as  required.  After  the  sixth 
week  knitted  bands  with  shoulder  straps  are 
preferable. 

Four  second-size  silk-and-wool  shirts. 

Six  pinning  blankets  made  of  white  flannel 
with  cotton  bands. 

Three  flannel  skirts. 

Three  white  skirts. 

Six  night  slips  to  be  used  day  and  night 
for  five  or  six  weeks. 

Six  day  slips  as  plain  as  possible,  bishop 
style. 

Three  eiderdown  wrappers. 

Three  cashmere  sacques. 

THE  FIRST  DUTY  TO  THE  CHILD 
With  the  severing  of  the  umbilical  cord 


4  First  Duty  to  the  Child 

the  child  begins  an  independent  existence. 
It  is  made  to  cry,  the  eyes  and  mouth  receive 
attention,  when  it  is  wrapped  in  a  soft,  warm 
blanket  and  placed  out  of  draughts  until  it 
can  be  given  further  attention.  During  the 
excitement  of  the  occasion  and  the  needs  of 
the  mother  the  baby  is  sometimes  neglected, 
often  with  serious  consequences.  I  once 
saw,  with  another  physician,  a  fatal  case  of 
pneumonia  in  a  child  four  days  old,  the  dis- 
ease being  due  in  all  probability  to  neglect. 
It  must  not  be  forgotten  that  the  baby  has 
been  suddenly  transported  into  an  entirely 
different  sphere  of  action  from  that  to  which 
he  is  accustomed,  and  we  must  make  the 
change  as  easy  for  him  to  bear  as  possible. 
As  soon  as  the  nurse  can  devote  her  attention 
to  the  baby  he  should  be  gently  and  thor- 
oughly oiled  with  liquid  albolene  or  sweet  oil. 
This  is  to  be  followed  later  by  a  sponge  bath 
with  lukewarm  water  and  Castile  soap.  The 
stump  of  the  cord  should  be  dusted  with  some 
dry  antiseptic  powder  and  wrapped  in  dry, 
plain  sterile  gauze.  The  cord,  particularly 
at  its  junction  with  the  abdomen,  should  be 
thoroughly  dusted  twice  a  day.  When  it 
falls  off,  the  parts  should  be  kept  dusted  and 


The  Well  Baby  5 

dry  until  cicatrization  is  complete.  The 
following  powder  has  proven  most  satis- 
factory in  my  hands: 

Salicylic  acid,  15  grains. 

Powdered  starch,  i  ounce. 

Powdered  oxide  of  zinc,  i  ounce. 

THE  WELL  BABY 

In  order  to  appreciate  disease  or  failure  in 
proper  growth  and  development,  it  is  neces- 
sary to  know  what  constitutes  a  well  baby. 
The  well  baby  grows  steadily,  shows  an  in- 
crease in  weight  of  from  five  to  six  ounces  a 
week,  the  muscles  are  firm,  the  skin  clear, 
and  the  eyes  bright.  When  hungry  he  makes 
it  known  by  crying  lustily.  At  the  com- 
pletion of  the  feeding  he  gives  evidence  of 
comfort  by  drowsiness,  or  by  falling  asleep. 
There  are  two  or  three  soft  yellow  stools 
daily.  After  the  second  month  the  well  baby 
appreciates  a  moderate  amount  of  attention, 
and  is  attracted  to  bright  objects  and  pleas- 
ant faces.  His  sleep  is  restful,  and  he  wakes 
good-natured  unless  he  is  hungry.  It  is 
not  to  be  understood  that  the  well  baby 
cries  only  when  hungry.  lie  often  cries 
while  being  undressed,  when  the  clothing 


6  The  Well  Baby 

is  uncomfortable,  when  objectionable  people 
appear  before  him,  or  when  suffering  from 
pain. 

At  the  fourth  or  fifth  month  he  should  be 
able  to  hold  his  head  erect  without  support; 
from  the  sixth  to  the  seventh  month — at 
this  time  the  first  tooth  is  usually  cut — he 
acquires  the  power  of  sitting  up  without 
assistance;  from  the  ninth  to  the  tenth 
month  he  begins  to  creep,  and  from  the 
twelfth  to  the  eighteenth  month  he  learns 
to  walk  alone.  A  very  few  children  walk 
alone  before  the  twelfth  month ;  the  great 
majority,  however,  are  from  fifteen  to  eigh- 
teen months  before  this  important  feat  is 
accomplished.  There  is  nothing  to  be  gained 
and  much  harm  may  be  done  by  parents 
favoring  early  walking.  When  the  child 
learns  to  walk  unaided,  it  is  usually  safe  to 
allow  him  to  continue,  unless  he  is  very 
heavy.  A  child  four  or  five  pounds  over 
weight  should  be  carefully  watched  and  the 
walking  prevented  to  any  extent  until  he  is 
seventeen  or  eighteen  months  of  age.  Early 
walking  in  these  heavy  children  is  very  apt 
to  produce  fiat  feet,  knock-knee,  or  bowed- 
legs. 


Weight  of  the  Well  Baby         7 


THE  WEIGHT  OF  THE  WELL  BABY 


BOYS 

GIRLS 

Average  weight  at  birth 

7.55  Ibs. 

7.16  Ibs. 

three  months 

n-75 

"•5 

six  months 

1  6. 

15-5 

nine  months 

1  8. 

17-75 

twelve  months 

20. 

19.8 

eighteen  months 

22.8 

22. 

two  years 

26.5 

25-5 

three  years 

31-5 

3°- 

four  years 

35- 

34- 

five  years 

41.2 

39-8 

six  vears 

45-i 

43-8 

Even-  child  under  one  year  of  age  should 
he  weighed  once  a  week.  The  very  weak 
and  delicate  and  those  who  are  being  put 
through  a  new  course  of  dietetic  treatment 
on  account  of  failure  in  growth,  should  be 
weighed  two  or  three  times  a  week.  An 
infant  is  doing  fairly  well  who  gains  on  an 
average  four  ounces  a  week,  ten  months  in 
the  year.  Such  a  child,  however,  needs  care- 
ful watching.  If  he  gains  from  six  to  ten 
ounces  a  week,  we  are  perfectly  satisfied  with 
his  progress.  The  use  of  the  weight  chart 
I  do  not  advise.  Such  a  chart,  while  recom- 
mended by  many  well-known  writers,  has 
been  the  cause  of  serious  trouble.  The 
mother  and  nurse  wish  the  baby's  weight 


8         Weight  of  the  Well  Baby 

chart  to  make  a  good  showing — to  show 
something  phenomenal  if  possible — for  the 
admiration  of  relatives  and  friends.  Some 
perfectly  well,  vigorous  babies  increase  in 
weight  slowly,  but  a  gain  of  only  four  or  five 
ounces  a  week — below  the  standard  of  her 
neighbor  or  the  normal  weight  line  on  the 
chart — makes  a  very  unsatisfactory  chart, 
and  the  mother  in  consequence  begins  to 
worry,  fearing  that  her  baby  is  not  being 
properly  nourished.  Worry  and  anxiety 
have  caused  the  milk  of  hundreds  of  mothers 
to  fail,  and  rendered  further  nursing  impos- 
sible. If  the  babe  is  wet-nursed  and  the 
.chart  does  not  show  a  large  gain,  the  mother 
scolds,  the  family  generally  is  dissatisfied, 
the  wet-nurse  becomes  angry,  and,  fearing  lest 
she  lose  her  position,  her  milk  soon  fails  and 
she  is  unable  to  nurse  the  baby.  If  the  baby 
is  bottle-fed,  there  is  a  strong  tendency  to 
overfeed  him  in  order  to  make  a  pretty  chart, 
and  as  a  result  the  child  is  made  ill. 

The  gain  in  weight  is  much  less  in  summer 
than  during  the  cooler  months.  I  have  seen 
many  children  in  perfect  health  pass  through 
July  and  August  without  gaining  an  ounce; 
but  with  the  arrival  of  cooler  weather  they 


How  to  Lift  the  Baby 


9 


will  surely  make  up  for  the  time  lost.  There 
is  usually  a  decided  loss  in  weight  the  first 
four  days  of  life.  This  loss — from  a  quarter 
to  a  half  pound — -will  usually  be  regained  in 
five  or  six  days  if  the  child  is  properly  fed. 
At  the  end  of  the  first  year  the  child  should 
weigh  two  and  one-half  times  as  much  as  at 
birth.  There  should  be  a  gain  of  about  seven 
pounds  during  the  second  year. 

HEIGHT    IN    INCHES    FROM    BIRTH    TO 
SIXTH  YEAR 


At  Birth. 

6  months 

12  months 

Boys,  20.6 

25-4 

29 

Girls,  20.  5 

25 

28.7 

18  months 

Two  years 

Three  years 

Boys,  30 

32-5 

35 

Girls,  29.  7 

32-5 

35 

Four  years  Five  years          Six  years 


Boys,  38 
Girls,  38 


41.7 
41.4 


44.1 
43-6 


HOW  TO  LIFT  THE  BABY 

A  baby  should  be  lifted  by  placing  one 
hand  under  the  buttocks  and  the  other  under 
the  head.  Until  the  fifth  or  sixth  month  is 


io  The  Nursery 

reached,  a  child  should  never  be  raised  with 
the  head  unsupported. 

THE  NURSERY 

The  nursery  should  he  the  largest  and  best 
ventilated  room  in  the  house.  In  a  city 
home  it  is  best  to  have  it  on  the  third  or 
fourth  floor  with  a  southern  exposure.  In 
apartments,  quiet  and  the  possibility  of  free 
ventilation  and  sunlight  must  be  considered 
in  selecting  the  room.  For  the  sake  of  quiet 
the  nursery  should  not  communicate  with 
the  sleeping-rooms  of  older  children. 

In  placing  children  in  sleeping-rooms  or 
in  a  nursery,  or  in  estimating  the  capacity  of 
hospital  wards  for  children,  it  is  to  be  re- 
membered that  at  least  one  thousand  cubic 
feet  of  air-space  should  be  allowed  to  each 
child. 

The  floor  of  the  nursery  should  not  be 
carpeted.  A  hard-wood  floor  is  best.  If 
this  is  not  possible,  covering  the  floor  with 
oil-cloth  or  linoleum  is  always  possible. 
This  can  be  cleaned  with  a  damp  cloth  every 
day.  A  broom  should  never  be  used  in  a 
nursery.  Paint  or  hard  finish  on  the  walls 


The  Nursery  n 

is  preferable  to  paper.  There  should  be  at 
least  two  windows  and  an  open  fireplace.  If 
possible,  the  bath-room  should  be  connected 
with  the  nursery,  to  be  used  not  only  for 
bathing  the  child  but  as  a  '  'changing  room." 
The  child's  napkins  should  not  be  changed 
in  its  living-room  if  it  can  be  avoided.  It  is 
needless  to  say  that  napkins  should  never  be 
dried  in  the  nursery. 

Steam  heat  as  ordinarily  used  to-day  is  the 
least  desirable  means  of  heating,  on  account 
of  its  uncertainty.  In  many  New  York 
apartments  of  the  better  class  the  fires  are 
banked  at  10  P.  M.;  the  temperature  when 
the  child  retires  is  from  70°  to  80°  F.  or  more ; 
by  five  or  six  o'clock  in  the  morning  a  fall  to 
from  50°  to  60°  V.  has  taken  place.  Such  a 
change  in  the  temperature  with  the  tendency 
of  children  to  kick  off  the  bed-clothes  ex- 
plains many  cases  of  tonsillitis  and  bron- 
chitis. The  temperature  of  the  nursery 
should  be  kept  as  even  as  possible.  When 
for  any  reason  this  cannot  be  controlled,  it 
is  best  to  have  two  means  of  heating,  so  that 
when  one  fails  the  other  may  be  used.  The 
open-grate  fire  or  a  small  wood-stove  is  best. 
Gas  ought  never  to  be  employed  as  a  means 


12  The  Nursery 

of  heating  a  child's  sleeping-room,  on  account 
of  the  rapid  exhaustion  of  the  oxygen  which 
results  from  its  use. 

The  furniture  of  the  nursery  should  be  of 
the  plainest.  Hard-wood  chairs  and  tables 
with  enamel  or  brass  cribs  or  bedsteads 
should  be  used.  There  should  be  no  article 
of  furniture  or  furnishings  in  a  nursery  that 
cannot  be  washed.  There  should  be  in  the 
bath-room  or  in  some  room  adjoining,  a  pail 
containing  some  disinfectant  solution,  such 
as  carbolic  acid,  one  tablespoonful  to  two 
gallons  of  water,  in  which  the  napkins  are 
placed  as  soon  as  soiled. 

There  should  be  two  shades  at  each  win- 
dow, a  light  and  a  dark  shade,  so  that  it  will 
be  possible  to  darken  the  room  during  the 
sleeping  time,  as  well  as  to  exclude  the  early 
morning  light,  which  is  the  usual  cause  of  too 
early  waking.  Babies  should  be  taught  to 
sleep  until  at  least  six  o'clock  in  the  morning. 
This  is  far  better  for  the  child  and  also  for 
the  mother  if  she  occupies  the  same  room. 
The  unnecessary  habit  of  an  early  waking  at 
four  or  five  o'clock  will  in  most  instances 
readily  be  broken  by  keeping  the  room  dark. 

The  nurserv   should  have  suitable  means 


Maternal  Nursing  13 

for  ventilation.  For  this  purpose,  aside 
from  the  fireplace,  I  have  found  the  window 
board  of  no  little  service.  It  can  be  made 
of  any  width.  Ordinarily,  I  have  it 
made  about  four  inches  wide.  It  is  sawed 
so  as  to  fit  tightly  under  the  lower  sash.  This 
leaves  an  open  space  corresponding  to  the 
width  of  the  board  between  the  upper  and 
lower  sash,  and  allows  the  entrance  of  a  cur- 
rent of  air  which  is  directed  upward.  There 
should  be  a  thermometer  in  every  child's 
living-room  or  nursery.  It  should  register 
from  70°  to  72°  F.  by  day  and  from  60°  to 
65°  F.  by  night.  The  nursery  should  be 
given  an  hour's  airing  twice  a  day.  The 
child  should  sleep  alone  in  its  crib.  It  should 
not  sleep  with  an  adult  or  an  older  child. 
The  old-fashioned  cradle  in  which  genera- 
tions have  been  rocked  may  be  an  interest- 
ing heirloom,  but  under  no  circumstances 
should  it  be  removed  from  its  place  in  the 
garret. 

MATERNAL  NURSING 

Writers  on  this  subject  are  very  apt  to 
state  that  the  ability  of  the  mother,  par- 
ticularly among  the  well-to-do,  to  fulfil  this 


M  Maternal  Nursing 

most  important  function  is  surely  decreasing. 
This  may  have  been  a  true  statment  a  dec- 
ade ago ;  at  the  present  time,  however,  I  am 
sure  it  is  erroneous.  In  my  own  medical 
life  I  have  seen  a  change  for  the  better,  par- 
ticularly during  the  past  five  years.  The 
young  mother  of  today  is  better  able  to  nurse 
her  offspring  than  was  her  sister  five  or  ten 
years  ago.  I  attribute  this  to  the  fact  that 
the  youth  of  the  present  day  are  more  vigor- 
ous, more  nearly  normal  individuals  than 
were  those  of  a  decade  ago.  The  inability 
to  perform  the  nursing  function  so  that  it  will 
be  successful  has  always  been  attributed  to 
the  mother  per  se.  This,  I  think,  is  an  error. 
Not  every  breast-milk  for  two  or  three  weeks 
after  parturition  is  ideal,  as  I  have  found  by 
the  examinations  of  hundreds  of  them.  If  a 
child  is  bom  with  a  generally  enfeebled  vital- 
ity, it  keenly  feels  any  slight  abnormality  in 
the  milk,  or  it  may  not  be  able  to  digest  per- 
fectly normal  milk;  in  either  event,  the  milk- 
disagrees  and  the  nursing  is  discontinued. 
Breast-milk  during  the  first  two  or  three 
weeks  of  the  infant's  life  is  produced  under 
conditions  which  are  unfavorable — condi- 
tions which  do  not  indicate  the  possibilities 


Maternal  Nursing  15 

of  the  breast  as  a  secreting  organ.  Follow- 
ing, as  it  does,  upon  the  stress  of  confinement, 
it  is  not  indicative  of  what  may  be  possible 
later  when  the  customary  life  and  daily  habits 
are  resumed.  Repeatedly  I  have  found  a 
very  high  fat  or  a  high  proteid,  or  both,  dur- 
ing the  first  week  or  two,  entirely  corrected 
later  without  interference.  This  condition 
at  the  time  was  considered  sufficiently  serious 
to  warrant  the  discontinuance  of  nursing  on 
the  part  of  a  weakly  infant,  while  in  a  vigor- 
ous infant  it  would  be  entirely  ignored. 

The  change  which  enables  more  mothers 
successfully  to  nurse  their  infants  is  due  to 
two  causes — more  vigorous  fathers  and 
mothers  and  more  vigorous  offspring.  Fol- 
lowing this  line  of  reasoning,  the  more  normal 
the  mother,  the  better  able  is  she  to  perform 
this  normal  function.  That  this  is  the  case 
is  due,  I  believe,  to  the  fact  that  growing 
girls  and  young  women  are  leading  more 
hygienic  lives  than  formerly.  The  making 
of  golf,  bicycle  and  horseback  riding,  boating, 
and  automobiling  popular  and  fashionable — 
in  short,  the  taking  of  girls  out-of-doors  and 
keeping  them  there  a  considerable  portion 
of  the  day — has  worked  a  marvellous  change 


1 6  Maternal  Nursing 

for  the  better,  both  physically  and  mentally. 
A  neurotic  mother  makes  the  poorest  pos- 
sible milk-producer.  Proportionate  to  the 
population,  there  are  fewer  neurasthenics 
among  the  young  women  to-day  than  there 
were  ten  years  ago,  and  there  will  be  still 
fewer  ten  years  hence.  At  the  present 
time  the  timid,  retiring  young  woman  of  the 
neurasthenic  type  is  not  popular  in  her  set. 
It  is  a  fortunate  thing  for  the  future  of  the 
human  race,  at  least  for  that  portion  of  it 
which  resides  in  the  United  States,  that  the 
young  woman  has  transferred  her  allegiance 
from  the  crochet  and  embroidery  needle  to 
the  golf  club.  It  may  be  said  that  our  argu- 
ment holds  only  with  the  wealthy  or  the  well- 
to-do.  Imitation  is  one  of  the  strongest 
characteristics  of  the  human  race,  and  this 
tendency  in  America  to  outdoor  hygienic 
living  pervades  all  classes.  Saturday  half- 
holidays,  the  excursions  and  outings  afforded 
by  reduced  rates  of  transportation,  are  much 
more  popular  than  they  were  ten  years  ago. 
Food  is  better  selected  and  better  prepared, 
owing  to  increased  knowledge  on  the  part  of 
the  people  as  to  \vl.nt  constitutes  proper 
nutrition.  These  are  facts,  in  spite  of  the 


Maternal  Nursing  17 

sensational  novelists  and  magazine- writers. 
A  feature  which  marks  an  important  ad- 
vance in  the  right  direction  is  the  establish- 
ment of  a  department  in  dietetics  and  food 
economics  in  the  New  York  Training  School 
for  Teachers.  The  Dean,  Dr.  James  E.  Rus- 
sell, in  establishing  this  course,  is  producing 
benefits  which  reach  farther  than  he  realizes. 
The  students  are  taught  food  values,  food 
preparation,  and  food  economics,  which  con- 
sists in  providing  for  a  given  amount  of 
money  the  most  nutritious  food  in  its  most 
attractive  form.  Hundreds  of  teachers  are 
sent  out  from  this  institution  every  year  to 
take  their  places  of  usefulness  as  instructors 
of  the  young  in  all  portions  of  the  country. 
Each  has  learned  something  of  food  values, 
and  better  still  each  has  had  impressed  upon 
him  or  her  the  importance  of  the  proper 
nutrition  of  a  growing  child.  They  are 
taught  that,  without  this,  the  best  possible 
type  of  adult  cannot  be  produced.  As  a 
result  of  such  instruction  they  will  be  of  far 
greater  service  in  their  fields  of  labor,  for  not 
only  can  they  teach  what  is  laid  clown  in  the 
books,  but,  what  is  equally  if  not  more  im- 
portant, they  are  competent  to  teach  those 


i8  Maternal  Nursing 

under  their  care  how  to  live;  and  those  who 
live  properly,  grow  properly,  following  out 
the  maxim  of  Herbert  Spencer  that  "the 
first  requisite  for  success  in  life  is  to  be  a  good 
animal;  and  to  be  a  nation  of  good  animals 
is  the  first  condition  of  national  prosperity." 
It  may  be  thought  that  we  have  wandered 
far  from  our  subject — maternal  nursing,  but 
such  is  not  the  case;  for  conditions  which 
relate  to  this  important  function,  even  re- 
motely, demand  our  respectful  consideration. 
The  food  and  care  of  the  growing  girl  have 
the  most  intimate  bearing  upon  her  future 
life,  and  if  she  is  to  be  called  upon  to  perform 
the  most  important  function  of  womanhood, 
she  surely  has  the  right  to  demand  that  she 
receive  during  her  girlhood  proper  prepara- 
tion, which  heretofore  has  too  often  been 
denied  her. 

It  is  not  pleasant  to  criticise  physicians; 
but  friendly  criticism  should  always  be  wel- 
comed. The  family  physician  does  not,  in 
a  great  majority  of  instances,  fulfil  his  func- 
tion, or  extend  his  field  of  usefulness  to  its 
full  capacity,  his  conception  of  duty  too  often 
including  only  the  sick.  Unsought  advice 
as  to  the  feeding  and  dailv  habits  of  a  child's 


Maternal  Nursing  19 

life,  I  find,  are  usually  welcomed  and  appre- 
ciated by  mothers.  In  practically  every 
instance,  according  to  my  observation,  errors 
in  a  child's  management  are  due  to  ignorance. 
Mothers,  no  matter  what  their  station  in  life, 
are  glad  to  do  what  is  for  the  best  interests 
of  their  children  when  it  is  made  clear  to 
them.  It  is  the  duty  of  the  physician  to 
take  the  mother  into  his  confidence  and  ex- 
plain to  her  the  reasons  for  the  line  of  action 
advised.  When  she  appreciates  the  reason 
for  certain  procedures,  I  find  that  she  is  far 
more  apt  to  follow  them.  I  am  confident 
from  observations  upon  many  cases  that  if 
I  could  have  the  physical  direction  of  ten 
average  girls  in  any  station  in  life,  provided 
that  they  could  have  the  benefit  of  fresh  air 
and  good  food  from  infancy  to  adolescence, 
successful  nursing  mothers  could  be  made 
out  of  eight  of  them.  Certain  rules  of  life 
having  a  direct  bearing  on  nursing  lead  us 
nearer  the  ideal  and  may  enable  one  who 
otherwise  could  not  nurse  her  child  to  do  so 
successfully.  These  requirements,  it  will  be 
seen,  are  laid  along  common-sense  lines 
and  cause  no  hardship  or  mental  distress 
one  of  the  chief  requirements  of  a  nursing 


20  Maternal  Nursing 

woman  being  that  she  shall  be  mentally 
normal. 

There  are  few  conditions  in  which  we  arc 
called  to  act  so  variable  and  so  uncertain  as 
is  the  production  of  breast-milk.  Breast- 
milk  is  one  of  the  most  precious  substances. 
It  is  invaluable,  unless  we  can  put  a  value  on 
human  life.  The  most  successful  nursing 
age  is  between  the  twentieth  and  thirty -fifth 
years.  I  have,  however,  seen  it  successfully 
carried  on  in  a  girl  of  fourteen,  in  a  woman 
of  fifty-two,  and  in  the  much-abused  society 
girl,  while  I  have  seen  it  fail  absolutely  in 
peasant  women  fresh  from  the  fields  of 
Hungary  and  Bohemia.  I  have  seen  those 
in  whom  at  first  the  nursing  was  most  un- 
satisfactory develop  into  perfect  nurses. 

Some  mothers  will  be  able  to  carry  on  the 
nursing  for  only  two  months;  others,  three, 
five,  seven,  or  nine  months.  In  my  expe- 
rience, whether  in  out-patient  or  in  private 
practice,  it  is  extremely  rare  for  the  breast- 
milk  to  be  sufficient  for  the  child  after  the 
ninth  month, 

The  following  can  be  laid  down  as  nursing 
axioms; 

A   diet   similar  to   what   the   mother  was 


Maternal  Nursing  21 

accustomed  to  before  the  advent  of  mother- 
hood should  be  taken. 

There  should  be  one  bowel  evacuation 
daily. 

There  should  be  from  three  to  four  hours 
daily  spent  in  the  open  air  with  exercise 
which  does  not  fatigue. 

There  should  be  at  least  eight  hours'  sleep 
out  of  every  twenty-four. 

There  should  be  absolute  regularity  in 
nursing. 

There  should  be  no  worry  and  no  excite- 
ment. 

The  mother  should  be  temperate  in  all 
things. 

The  diet. — I  have  many  times  been  con- 
sulted by  nursing  mothers  because  the  nurs- 
ing was  unsuccessful  or  a  partial  failure,  and 
have  found  that  their  diet  has  been  restricted 
to  an  extreme  degree.  To  put  on  a  greatly 
restricted  diet  a  robust  young  mother  who 
has  always  eaten  bountifully  of  a  generous 
variety  of  foods  is  one  of  the  best  means  of 
curtailing  the  quantity  and  lowering  the 
quality  of  her  milk-supply.  When  asked  to 
prescribe  a  diet  I  tell  them  to  eat  practically 
as  they  were  accustomed  to  before  the  advent 


22  Maternal  Nursing 

of  pregnancy  and  motherhood.  That  this 
particular  vegetable  or  that  particular  fruit 
should  be  forbidden,  on  general  principles  is 
a  fallacy.  Food  that  the  patient  can  digest 
without  inconvenience  is  a  safe  food  so  far 
as  the  nursing  is  concerned,  as  may  readily 
be  determined  in  any  given  case.  If  a  wide 
range  of  diet  is  prescribed  in  some  individuals, 
a  plain,  more  or  less  restricted  diet  is  desirable 
in  others.  Many  a  wet-nurse  who  has  been 
carefully  selected,  who  to  the  best  of  our 
judgment  should  prove  satisfactory,  utterly 
fails  in  a  few  days  to  fulfil  the  duties  of  the 
office  for  which  she  was  chosen.  In  not  a 
few  instances  the  failure  is  due  to  a  very  full 
diet  of  unusual  articles  of  food,  the  existence 
of  which,  in  many  instances,  she  never 
dreamed  of.  Indigestion  and  constipation 
follow,  and  both  the  nurse  and  the  baby  are 
made  ill  and  the  woman's  usefulness  ceases. 
A  woman  who  has  lived  and  been  well  on  the 
diet  and  food  found  in  the  home  of  the  labor- 
ing man,  whether  in  the  city  or  country,  will 
make  a  far  better  wet-nurse  on  this  diet  than 
if  she  indulges  in  food  to  which  she  is  entirely 
unaccustomed.  The  diet  of  a  nursing  mother, 
then,  should  in  general  be  as  above  stated. 


Maternal  Nursing  23 

Nursing  is  a  perfectly  normal  function, 
and  a  mother  should  be  permitted  to  carry 
it  out  along  only  natural  lines.  Inasmuch 
as  there  are  two  lives  to  be  provided  for 
instead  of  one,  more  food,  particularly  of  a 
liquid  character,  may  be  taken  than  she  may 
have  been  accustomed  to.  It  is  my  custom 
to  advise  that  milk  be  given  freely.  A  glass 
of  milk  may  be  taken  in  the  middle  of  the 
afternoon,  and  eight  ounces  of  milk  with 
eight  ounces  of  oatmeal  or  cornmeal  gruel  at 
bedtime,  if  it  does  not  disagree.  Our  only 
evidence  that  a  food  is  not  disagreeing  is  the 
condition  of  the  digestion.  When  any  article 
of  food  disagrees  with  the  mother,  or  if  she 
is  convinced  that  it  disagrees,  whether  or 
not  such  is  really  the  case,  the  food  should  be 
discontinued.  In  a  general  way,  milk  in 
quantities  not  over  one  quart  daily,  eggs, 
meat,  fish,  poultry,  cereals,  green  vegetables, 
and  stewed  fruit  constitute  a  basis  for  selec- 
tion. The  method  of  preparation  for  the 
different  meals  is  not  arbitrary. 

The  bowel  junction. — A  very  important 
and  often  neglected  matter  in  relation  to 
nursing  is  the  condition  of  the  bowels.  There 
must  be  one  free  evacuation  dailv.  For  the 


24  Maternal  Nursing 

treatment  of  constipation  in  nursing  women 
I  have  used  different  methods  in  many  cases. 
The  dietetic  treatment  does  not  promise 
much.  For  here,  again,  manipulation  of  the 
diet  may  interfere  with  the  milk  production. 
Three  methods  are  open  to  use:  massage, 
local  measures,  and  drugs.  Massage  is  avail- 
able in  comparatively  few  cases.  Local 
measures  consist  in  the  use  of  enemas  or 
suppositories.  Every  nursing  woman  under 
my  care  is  instructed  to  use  an  enema  at  bed- 
time if  no  evacuation  of  the  bowels  has  taken 
place  during  the  previous  twenty-four  hours. 
Many  out-patients,  in  whom  constipation  is 
very  prevalent,  indulge  in  excessive  tea- 
drinking,  taking  often  from  one  to  two  gallons 
of  tea  daily.  In  such  patients,  where  an 
absolute  discontinuance  of  the  tea-drinking 
is  often  impossible  and  not  absolutely  neces- 
sary, I  usually  allow  two  cups  a  day.  When 
a  laxative  is  necessary,  it  should  be  prescribed 
by  a  physician. 

Air  and  exercise.- — Outdoor  life  and  exer- 
cise are  desirable  here  as  they  arc  tinder  all 
other  conditions.  In  a  nursing  woman,  with 
her  added  responsibility,  they  arc  doubly  so. 
In  order  to  get  the  best  results,  exercise  or 


Maternal  Nursing  25 

work  should  so  be  adjusted  as  not  to  reach 
the  point  of  fatigue.  The  mother  whose 
nights  are  disturbed  should  be  given  the 
benefit  of  a  midday  rest  of  an  hour  or  two. 
She  should  have  at  least  eight  hours'  sleep 
out  of  every  twenty-four.  Certain  annoy- 
ances, anxieties,  and  worries  are  inseparable 
from  the  life  of  every  child-bearing  woman. 
It  should  be  our  duty,  however,  to  explain 
to  the  mother  and  to  other  members  of  the 
family  that  an  important  element  in  satis- 
factory nursing  is  a  tranquil  mind.  During 
the  lactation  period  she  should  be  spared  all 
unnecessary  care  and  petty  annoyances. 

Regularity  in  nursing.  The  breast  \vhich 
is  emptied  at  definite  intervals  invariably 
works  better  than  does  one  which  is  not,  not 
only  as  regards  the  quantity,  but  the  quality 
of  the  milk  as  well ;  so  that  system  in  breast- 
feeding is  almost  as  essential  to  milk-produc- 
tion as  to  its  digestion  and  assimilation. 

After  it  is  demonstrated  that  the  nursing 
is  progressing  satisfactorily  as  proved  by  the 
satisfied,  thriving  child,  I  begin  with  one 
bottle-feeding  daily.  The  advisability  is 
obvious;  in  case  of  illness  of  the  mother,  if 
she  is  called  away  from  home,  or  if,  for  any 


26  Maternal  Nursing 

reason,  the  child  cannot  have  the  breast,  the 
feeding  is  provided  for.  Another  advantage 
is  that  it  gives  the  mother  needed  freedom 
from  restraint.  She  is  thus  enabled  to  have 
the  benefit  of  a  change  of  scene.  Amuse- 
ments and  recreations  which  the  invariable 
nursing  period  denies  her  can  be  indulged  in. 
As  a  result  of  this  greater  freedom,  she  is  able 
to  supply  better  milk  and  to  continue  nursing 
longer  than  if  tied  continually  to  the  baby, 
no  matter  how  fond  she  may  be  of  it. 

Signs  of  successful  nursing. — The  child 
shows  a  gain  of  not  less  than  four  ounces 
weekly.  This  is  the  minimum  weekly  gain 
which  may  safely  be  allowed.  When  a  nurs- 
ing baby  remains  stationary  in  weight  or 
makes  a  gain  of  but  two  or  three  ounces  a 
week,  it  means  that  something  is  wrong,  and 
it  will  usually,  but  not  invariably,  be  found 
in  the  milk  supply.  When  the  bal  >y  is  nursed 
at  proper  intervals  and  the  supply  of  milk  is 
ample  and  of  good  quality,  he  is  satisfied  at 
the  completion  of  the  nursing.  If  he  is  under 
three  months  of  age,  he  falls  asleep  after  ten 
or  twenty  minutes  at  the  breast.  When  the 
nursing  period  again  approaches,  he  becomes 
restless  and  unhappy,  crying  lustily  if  the 


Maternal  Nursing  27 

nursing  is  delayed.  When  the  breast  is 
offered,  he  takes  it  greedily.  The  stools  are 
yellow  and  number  from  two  to  three  daily. 
The  weekly  gain  in  weight  under  such  con- 
ditions is  usually  from  six  to  eight  ounces. 

Signs  of  unsuccessful  nursing. — Theoreti- 
cally, every  normal  breast  baby  should  be  a 
thriving,  well  baby.  That  such  is  not  the 
case  is  an  unfortunate  fact.  The  standard 
established  for  a  well  baby  is  not  upheld  here. 
When  the  supply  of  milk  is  scanty  the  child 
remains  long  at  the  breast  and  cries  when  he 
is  removed.  He  shows  signs  of  hunger  before 
the  nursing  hour  arrives.  A  cause  of  failure 
in  breast-feeding,  and  probably  the  most 
frequent  cause,  is  a  scanty  milk-supply.  The 
chief  nutritional  elements  in  mother's  milk 
are:  fat,  3  to  4  per  cent.;  sugar,  7  per  cent.; 
proteid,  i .  5  per  cent.  Failure  may  be  due  to  a 
marked  disproportion  of  these  elements, 
which  may  cause  sufficient  indigestion  and 
resulting  loss  in  weight  to  necessitate  the 
discontinuance  of  nursing.  Thus  there  may 
be  a  high  fat — from  5  to  6  per  cent. ;  or  very 
low  fat — from  i  to  1.5  per  cent.  In  the  high- 
fat  cases  there  will  usually  be  diarrhoea  with 
green,  watery  stools.  The  child  strains  a 


28  Maternal  Nursing 

great  deal  and  there  are  green  stains  on  many 
of  the  napkins.  In  high-fat  cases  there  is 
also  regurgitation  or  vomiting  of  sour  mate- 
rial. Low  fat  means  deficient  nourishment 
and  may  cause  constipation.  Sugar  is  rarely 
a  cause  of  trouble  in  nursing  babies.  It  sel- 
dom varies,  ranging  from  5  to  7  per  cent,  in 
the  great  majority  of  breast-milks.  Young 
children,  further,  have  a  marked  toleration 
for  it.  The  proteid  of  mother's  milk  is  the 
most  frequent  cause  of  nursing  difficulties. 
Like  the  fat,  it  may  so  be  decreased  that 
nutritional  disorder  may  be  induced  in  the 
patient,  or  it  may  be  very  much  increased ; 
the  latter  being  usually  the  cause  of  colic  or 
constipation  in  otherwise  healthy  nursing 
infants.  In  such  infants  curds  may  be  found 
in  the  stools,  the  passage  of  which  is  always 
accompanied  by  a  great  deal  of  gas.  The 
milk  may  contain  the  normal  percentage  of 
fat,  sugar,  and  proteid,  but  be  scanty  in 
amount.  Instead  of  the  four  or  five  ounces 
to  which  the  child  is  entitled,  he  may  get  but 
one  or  two  ounces.  Whether  or  not  the 
quantity  is  sufficient  can  be  determined  by 
weighing  the  baby  before  and  after  each 
nursing,  for  twenty-four  hours.  One  ounce 


Maternal  Nursing  29 

of  breast-milk  practically  weighs  one  ounce 
avoirdupois.  The  quality  or  strengtn  is 
determined  by  an  examination  of  the  milk 
itself  by  the  physician.  Before  nursing,  the 
child  is  put  in  the  scales  without  undressing 
him  and  the  weight  noted.  He  is  allowed  to 
nurse  fifteen  minutes.  He  is  then  removed 
from  the  breast  and  weighed.  A  child  under 
one  week  should  have  gained  from  i  to  i| 
ounces;  at  three  weeks  of  age,  i£  to  2  ounces; 
four  to  eight  weeks  of  age,  2  t03  ounces;  eight 
to  sixteen  weeks  of  age,  3  to  4  ounces ;  sixteen 
to  twenty-four  \veeks  of  age,  4  to  6  ounces; 
six  to  nine  months  of  age,  6  to  8  ounces ;  nine 
to  twelve  months  of  age,  8  to  9  ounces. 

Of  course  arbitrary'  limits  cannot  be  fixed 
as  to  the  quantity.  Stationary  weight  or 
loss  in  weight  with  a  dissatisfied  child  usually 
means  defects  in  quantity  which  are  readily 
proved  by  the  weighing.  To  be  fed  at  the 
breast  may  also  cause  the  child  to  sutler  from 
an  excess  of  good  milk,  in  which  event  there 
will  be  vomiting  or  regurgitation,  usually 
associated  with  colic.  When  this  overfeed- 
ing continues,  dilatation  of  the  stomach 
develops,  vomiting  becomes  habitual,  the 
child  loses  in  weight,  and  the  breast-milk  is 


30  Maternal  Nursing 

said  not  to  agree,  and  often,  unfortunately, 
the  baby  is  weaned.  This  has  been  the  out- 
come in  scores  of  cases.  When  there  is 
habitual  vomiting  and  colic  in  a  nursing  baby, 
two  things  are  to  be  done — the  baby  must  be 
weighed  before  and  after  nursing,  and  the 
milk  must  be  examined. 

I  have  repeatedly  treated  children  for 
indigestion  who  were  entirely  relieved  by 
shortening  the  nursing  period.  Weighing 
the  baby  at  intervals  of  from  three  to  five 
minutes  and  noting  the  gain  has  shown  that 
the  three  or  four  ounces  which  may  be  the 
child's  stomach  capacity  was  obtained  in 
two,  three,  or  five  minutes,  the  excess  which 
the  child  took  over  this  amount  being  the 
cause  of  his  trouble.  Given  a  free,  full  breast 
and  a  vigorous  nurser,  and  one  ounce  will  be 
taken  in  one  minute.  When  the  nursing 
"gait"  is  established,  a  child  should  be  kept 
up  to  the  schedule.  There  are  few  more 
pernicious  teachings  than  that  a  baby  should 
be  allowed  to  nurse  when  he  wants  to  and  as 
long  as  he  wants  to.  The  idea  that  a  nursing 
infant  will  take  no  more  than  is  good  for  him 
is  the  fruit  of  inexperience.  Recently  a 
mother  consulted  me  in  regard  to  putting 


Maternal  Nursing  31 

her  one-month-old  baby  on  the  bottle,  as  he 
had  many  green  stools,  cried  a  great  part  of 
his  waking  hours,  and  weighed  but  a  few 
ounces  more  than  at  birth.  Her  milk  was 
supposed  to  be  "too  strong"  for  the  child. 
An  examination  of  the  breast  and  a  talk  with 
the  mother  satisfied  me  that  the  breast-milk 
was  not  at  fault.  An  examination  of  the 
milk  proved  it  to  be  good  average  milk — 3.5 
percent,  fat,  6  per  cent,  sugar,  1.45  per  cent, 
proteid.  A  one-day's  test  by  weighing  was 
decided  upon.  He  was  allowed  to  nurse  one 
minute  and  rest  one  minute.  During  the 
resting  period  he  was  weighed.  Weighing 
and  resting  him  in  this  way,  it  was  found 
that  in  three  minutes  he  got  from  3  to  3?, 
ounces  of  milk.  The  nursing  was  then  re- 
duced to  three  minutes  on  one  breast  and 
five  minutes  on  the  other,  which  was  the 
"slower"  breast  of  the  two.  Every  sign  of 
indigestion  promptly  disappeared  after  this 
change.  The  stools  became  normal  and  the 
infant  made  a  satisfactory  gain  in  weight  of 
one  ounce  daily. 

The  quantity  may  be  suitable  for  the  age 
of  the  child,  he  may  not  vomit  or  show  a  sign 
of  indigestion,  and  yet  he  may  not  thrive. 


32  Maternal  Nursing 

In  such  a  case  an  examination  or  repeated 
examinations  of  the  milk  at  intervals  of  two 
or  three  days  will  usually  show  that  it  is  poor, 
below  the  normal  perhaps  in  both  fat  and 
proteid.  Such  a  case  occurred  in  the  New 
York  Infant  Asylum.  A  Swedish  woman 
was  admitted  with  an  infant  two  months  old 
in  fair  condition.  She  had  an  abundance  of 
milk  and  asked  for  a  foster-child,  so  great 
was  her  discomfort  from  the  excessive  flowr 
of  milk.  The  weekly  weighings  of  the  chil- 
dren soon  revealed  that  there  was  no  growth, 
and  both  children  upon  examination  showed, 
after  a  few  weeks,  developing  rickets.  The 
milk  was  then  examined  and  was  found  defi- 
cient— fat  1.2  per  cent.,  sugar  5  per  cent.,  and 
proteid  0.73  per  cent. 

Signs  of  insufficient  nursing. — The  baby 
remains  long  at  the  breast,  perhaps  one-half 
to  three-quarters  of  an  hour.  When  re- 
moved, he  is  restless  and  uncomfortable. 
After  a  short  time,  in  an  hour  or  less,  he  is 
very  hungry  and  demands  frequent  nursings 
day  and  night. 

Management  of  abnormal  milk  conditions.— 
When  it  is  found  that  the  breast-milk  is  too 
strong  or  too  weak,  or  when  the  normal  ratios 


Maternal  Nursing  33 

of  fat,  sugar,  and  proteid  are  not  maintained, 
it  may  be  possible  to  increase  or  diminish  the 
milk  strength.  It  may  also  be  possible  to 
increase  either  the  fat  or  the  proteid  when 
desirable.  The  heavy  milk  will  usually  be 
found  in  mothers  who  are  robust,  who  eat 
heartily,  and  who  take  but  little  exercise. 
In  such  a  mother,  the  prescribing  of  a  plain 
diet,  allowing  red  meat  but  once  a  day,  dis- 
continuing the  malt  liquors  or  wine — which 
it  will  often  be  found  that  she  is  taking, — and 
directing  that  she  walk  a  mile  or  two  a  day, 
will  frequently  bring  the  milk  to  digestible 
proportions.  In  some  cases,  however,  this 
will  not  be  successful,  and  the  colic,  consti- 
pation, and  vomiting  continue,  even  though 
the  quantity  obtained  at  each  nursing  is 
within  normal  limits.  In  some  mothers  it 
will  be  impossible  to  change  the  mode  of  life, 
except  perhaps  as  to  the  discontinuance  of 
alcohol.  When  such  conditions  prevail,  the 
mother's  milk  may  be  modified  by  giving 
from  one-half  to  one  ounce  of  boiled  water 
or  plain  barley-water  before  each  nursing. 
This  is  a  procedure  to  which  I  frequently 
resort.  One  teaspoon ful  of  lime-water  added 
to  one  ounce  of  water  before  each  nursing  has 


34  Maternal  Nursing 

made  the  breast-milk  agree  when  otherwise 
it  would  have  been  impossible.  When  the 
milk  is  deficient  both  in  fat  and  proteid,  a 
diet  composed  largely  of  red  meat,  poultry, 
fish,  rye  bread,  or  whole-wheat  bread,  oat- 
meal, cornmeal,  with  two  or  three  pints  of 
milk  daily,  will  often  be  followed  by  an  in- 
crease both  in  fat  and  proteid.  The  use  of 
alcohol  in  moderate  amounts,  in  the  form  of 
malt  liquors  or  wine,  will  usually  increase 
the  fat.  I  have  frequently  seen  it  advance 
2  per  cent,  in  from  two  to  three  days.  Disap- 
pointments in  improving  the  quantity  or 
quality  of  the  breast-milk,  however,  are 
frequent. 

In  addition  to  the  one  bottle  which,  for 
reasons  above  mentioned,  is  given  early  in 
the  child's  life,  I  find  it  necessary  at  the  sev- 
enth month  to  add  an  extra  bottle  or  two. 
Usually  at  this  time  the  proteid  in  human 
milk  begins  to  diminish  in  quantity,  and  as 
this  is  the  most  important  nutritional  cle- 
ment, an  insufficient  quantity  at  this  rapidly 
growing  period  of  life  is  a  matter  of  no  little 
importance.  At  the  twelfth  month,  with 
yen,'  few  exceptions,  my  nursing  babies  are 
weaned  from  necessity.  At  this  age  exclu- 


Maternal  Nursing  35 

sive  nursings,  if  one  considers  the  best  in- 
terests of  the  child,  are  practically  out  of 
the  question.  Out  of  many  thousands  of 
mothers  I  recall  but  one  instance  where  a 
mother  was  able  successfully  to  nurse  her 
child  after  the  twelfth  month.  This  re- 
markable woman,  the  mother  of  six  children, 
had  nursed  every  one  of  them  exclusively 
and  successfully  up  to  the  fifteenth  or  the 
eighteenth  month. 

Mixed  feeding. — With  a  diminution  in  the 
amount  of  milk  secreted,  the  breast  milk, 
must,  of  course,  be  supplemented  by  modi- 
fied cow's  milk.  This  method  of  feeding  is 
usually  successful.  If  the  mother  of  a  six- 
months-old  baby  can  satisfactorily  nurse 
him  three  times  in  twenty-four  hours,  he  is 
given,  in  addition,  three  bottle-feedings  in 
the  twenty-four  hours,  in  this  way  supple- 
menting the  mother's  milk.  It  is  best  when 
using  mixed  feedings  to  alternate  the  breast 
and  the  bottle.  The  modified  milk  strength 
should  be  that  which  is  suitable  for  the  aver- 
age child  of  his  age.  (See  Infant  Feeding, 
page  54.)  In  beginning  the  use  of  cow's 
milk,  however,  it  must  be  remembered  that 
at  first  a  weaker  strength  must  be  used  than 


36  Maternal  Nursing 

the  child  will  require  for  growth,  this  weaker 
food  being  necessary  in  order  gradually  to 
accustom  him  to  the  change  of  food.  If  too 
strong  a  cow's-milk  mixture  is  given  at  first, 
it  will  be  very  apt  to  disagree,  causing  colic 
and  vomiting.  Later,  when  the  child  has 
become  accustomed  to  the  new  food,  a 
stronger  mixture  may  be  given.  When  a 
mother  cannot  give  her  infant  at  least  two 
satisfactory  breast-feedings  daily,  it  is  better 
to  wean  the  child. 

Maternal  conditions  under  which  nursing 
is  forbidden. — When  the  mother  has  tuber- 
culosis in  any  of  its  various  forms  or  mani- 
festations, whether  it  involves  the  glands, 
the  joints,  or  the  lungs,  breast-feeding  is  to 
be  forbidden.  In  epilepsy  and  syphilis  nurs- 
ing is  likewise  forbidden.  In  nephritis  and 
malignant  disease  of  any  nature,  and  in 
chorea,  nursing  should  be  discontinued. 
Women  who  are  rapidly  losing  weight  should 
not  continue  nursing  their  infants.  In  case 
of  serious  illness  of  any  nature,  such  as 
typhoid  fever,  pneumonia,  or  diphtheria, 
and  upon  the  advent  of  pregnancy,  nursing 
should  be  stopped. 

Conditions    which    may   temporarily    pro- 


Maternal  Nursing  37 

d uce  an  unfavorable  effect  upon  the  breast-milk, 
but  not  necessitate  the  discontinuance  of  nurs- 
ing.— The  advent  of  the  first  menstruation 
period  particularly,  and  in  some  cases  of  every 
menstruation  period,  is  attended  with  an 
attack  of  colic  or  indigestion  on  the  part  of 
the  child,  rarely  sufficient,  however,  to  neces- 
sitate the  discontinuance  of  the  nursing  even 
for  a  single  day. 

Factors  influencing  the  mental  conditions 
of  the  mother,  such  as  anger,  fright,  worry, 
shock,  distress,  sorrow,  or  the  witnessing  of 
an  accident,  may  affect  the  milk  secretion 
sufficiently  to  cause  no  little  discomfort  to 
the  child,  and  oftentimes  the  temporary 
lessening  of  the  flow  for  a  day  or  two.  The 
influence  of  the  mental  state  upon  the  char- 
acter of  the  milk  was  early  brought  to  my 
attention  while  resident  physician  at  the 
Country  Branch  of  the  New  York  Infant 
Asylum.  In  this  institution  there  were 
usually  about  two  hundred  nursing  mothers, 
the  majority  of  them  from  the  lower  walks 
of  life,  at  least  95  percent,  of  the  infants  being 
illegitimate.  The  necessity  of  placing  a 
considerable  number  of  these  mothers  in 
wards,  and  their  living  thus  in  close  contact, 


38  Maternal  Nursing 

gave  rise  to  rather  frequent  disputes,  and 
not  infrequently  to  fistic  encounters  of  a 
decidedly  vigorous  character.  After  a  par- 
ticularly active  disturbance,  several  nursing 
infants  in  the  ward  would  be  taken  suddenly 
ill,  usually  with  vomiting,  diarrhoea,  and 
fever.  When  two  or  more  infants  were  thus 
discovered  ill,  we  soon  learned  to  know  the 
cause  when  inquiry  or  evidence  furnished  by 
hasty  inspection  of  the  mother  showed  that 
she  had  been  particularly  active  in  the  affair. 
A  small  proportion  of  the  mothers  were  from 
the  better  walks  of  life.  Letters  of  forgive- 
ness or  reproach  or  visits  of  a  like  nature  from 
fathers,  mothers,  or  sisters,  have  brought 
many  a  sick  baby  to  my  attention  and  caused 
me  man}-  anxious  moments. 

Conditions  which  call  for  temporary  dis- 
continuance of  nursing.- — Inuring  an  acute 
illness  with  fever,  such  as  indigestion,  ton- 
sillitis, and  minor  illnesses  of  a  like  nature, 
nursing  should  be  discontinued  for  a  day  or 
two.  When  the  infant  is  removed  from  the 
breast,  it  should  be  our  effort  to  maintain 
the  flow  of  milk.  This  is  best  done  by  empty- 
ing the  breast  with  a  breast-pump  (page  46) 
at  the  usual  nursing  period  until  the  time 


Maternal  Nursing 


39 


arrives  when  the  nursing  may  he  resumed. 
In  such  conditions  the  advantage  of  having 
the  baby  accustomed  to  one  bottle  a  day 
will  at  once  be  appreciated. 

Care  of  the  nipples. — Six  hours  after  de- 
li very  or  confinement,  the  nipples  should  be 
washed  with  a  saturated  solution  of  boric 
acid  and  the  child  put  to  the  breast  and  nurs- 
ing attempted.  After  this,  the  attempts  at 
nursing  should  be  repeated 
every  four  hours,  although 
the  milk  does  not  appear 
in  the  breasts  until  from 
forty -eight  to  seventy-two 
hours  after  the  birth  of  the 
child.  Colostrum  may  be 
present,  which  is  useful  as 
a  laxative  and  may  satisfy 
the  child.  A  further  ad- 
vantage of  the  nursing  at 
this  time  is  that  it  grad-  FIG.  2.  NIPPLK-SHIEI.D 
ually  accustoms  both  the 
nipple  and  the  infant  to  what  will  be  required 
of  them  later.  Immediately  after  the  nurs- 
ing the  nipple  should  be  carefully  washed 
with  a  saturated  solution  of  boric  acid  and 
thoroughly  but  gently  dried.  A  baby  should 


40  Maternal  Nursing 

never  be  allowed  to  nurse  on  a  cracked  or  fis- 
sured nipple.  For  this  very  painful  condition 
a  nipple-shield  (Fig.  2)  should  always  be  used. 

Giving  of  water. — From  one-half  to  one 
ounce  of  a  i  per  cent,  solution  of  milk-sugar 
should  be  given  the  infant  every  two  hours 
until  the  milk  appears  in  the  breast.  Other- 
wise there  will  be  unnecessary  loss  in  weight 
and  perhaps  a  high  degree  of  fever  due  to 
inanition. 

If  the  child  is  restless  and  uncomfortable, 
it  is  safe  to  conclude  that  he  is  thirsty,  and 
one  ounce  of  the  sugar-water  will  usually 
satisfy  him.  With  the  commencement  of 
nursing,  acctistom  the  baby  to  -getting  his 
food  at  regular  intervals. 

Frequency  of  nursings. — The  new-born 
infant  is  entitled  to  ten  nursings  in  twenty- 
four  hours.  From  6  A.M.  to  10  P.M.,  inclu- 
sive, there  should  be  nine  nursings.  There 
may  be  one  nursing  at  2  or  3  A.M.  As  the 
child  becomes  older  less  frequent  nursings 
are  required.  The  following  table  will  be 
found  useful  in  this  connection : 

Third  to  the  twenty-first  day 10   nursings. 

Third  to  the  sixth  week 9 

Six  to  the  twelfth  week.  .    8 


The  Wet-Nurse  41 

Third  to  the  fifth  month 7   nursings. 

Fifth  to  the  seventh  month 6-7 

Seventh  to  the  twelfth  month 5-6        " 

THE  WET-NURSE 

We  are  called  upon  to  select  a  wet-nurse 
under  various  conditions.  In  a  few  families, 
particularly  in  those  who  have  had  disastrous 
feeding  experiences,  we  are  asked  that  no 
attempts  at  artificial  feeding  be  made,  but 
that  a  wet-nurse  be  engaged  in  advance  of 
the  confinement  so  as  to  be  ready  when  the 
time  for  her  service  arrives.  Usually,  how- 
ever, our  minds  turn  to  the  wet-nurse  when 
nutrition  by  other  methods  is  a  failure.  It 
is  well  to  remember  in  this  connection  that 
it  is  not  wise  to  postpone  our  resort  to  the 
wet-nurse  too  long — until  every  chance  for 
her  being  of  assistance  has  passed.  It  may 
take  a  few  days'  observation  or  but  a  single 
glance  at  one  of  these  difficult  feeding  cases 
for  us  to  decide  whether  a  wet-nurse  must 
be  secured.  Certain  it  is  that  in  a  few  cases 
we  cannot  do  without  them.  I  see  perhaps 
two  or  three  cases  a  year,  usually  in  consul- 
tation, in  which  I  insist  that  further  attempts 
at  artificial  feeding  be  discontinued  because 
of  the  reduced  condition  of  the  patient. 


42  The  Wet-Nurse 

In  the  selection  of  a  wet-nurse  the  age 
during  which  nursing  is  most  successfully 
carried  on  is  to  be  remembered.  Other 
things  being  equal,  a  wet-nurse  should  not 
be  under  twenty-two  or  over  thirty-five 
years  of  age.  The  peasant  women  of  the 
continent  of  Europe  make  the  best  wet- 
nurses.  A  woman  should  not  be  selected 
as  a  wet-nurse  without  a  thorough  examina- 
tion both  of  herself  and  of  her  infant.  She 
must  be  free  from  skin  diseases,  tuberculosis, 
and  syphilis.  Whether  she  is  stout  or  thin, 
tall  or  short,  amounts  to  little.  Neither  can 
we  place  much  reliance  on  the  size  of  her 
breasts.  Although  full,  firm  breasts  and 
prominent  nipples  are  desirable,  the  best 
indication  as  to  her  nursing  ability  is  the 
condition  of  her  baby.  1  or  this  reason  it 
is  best  not  to  select  a  woman  before  her  baby 
is  four  weeks  old,  for  by  that  time  his  physi- 
cal condition  will  indicate  with  considerable 
accuracy  the  kind  of  food  he  has  been  getting. 
The  age  of  the  wet-nurse's  milk  need  not 
correspond  with  the  age  of  the  patient  for 
whom  she  is  engaged.  As  far  as  age  is  con- 
cerned, a  breast-milk  from  four  weeks  to 
three  months  old  will  answer  for  any  infant. 


The  Wet-Nurse  43 

The  results  attending  the  first  few  days  of 
wet-nursing  are  often  most  disappointing. 
The  radical  change  which  takes  place  in  the 
nurse's  habits  of  life,  the  leaving  of  her  own 
child  to  the  care  of  others,  sometimes  pro- 
duces nervous  conditions  which  may  have  a 
decidedly  unfavorable  influence  upon  her 
milk.  So  before  arriving  at  the  conclusion 
that  she  will  not  answer  in  a  given  case,  she 
should  have  time  to  adjust  herself  to  the 
changed  conditions.  Many  a  good  wet- 
nurse  has  been  ruined,  so  far  as  her  usefulness 
as  a  milk-producer  is  concerned,  by  over- 
indulgence at  the  table.  She  has  been  accus- 
tomed to  a  very  plain  diet  and  some  work, 
which  necessarily  means  exercise.  Upon 
assuming  her  new  office  she  is  temporarily 
the  most  important  member  of  the  household, 
next  to  the  baby,  and  articles  of  food  are 
supplied  to  which  she  is  entirely  unaccus- 
tomed and  of  which  she  eats  plentifully. 
The  result  is  an  attack  of  indigestion  with 
fever,  the  baby  is  made  ill,  and  the  usefulness 
of  the  wet-nurse  in  the  family  ceases.  These 
women  usually  do  best  upon  a  plain  diet  of 
meat,  poultry,  fish,  vegetables,  cereals,  and 
milk.  If  they  are  accustomed  to  taking 


44  The  Wet-Nurse 

beer,  one  bottle  daily  may  be  permitted. 
Coffee  may  be  allowed  to  the  extent  of  one 
cup  daily,  and  of  tea  not  more  than  two  cups 
should  be  allowed.  Women  of  this  class  are 
almost  invariably  neglectful  of  the  bowel 
function,  so  that  this  must  be  attended  to. 
One  free  evacuation  should  take  place  daily. 
As  a  rule,  the  wet-nurse  has  been  accustomed 
to  work  and  will  be  more  contented  and 
happy  when  her  time  is  occupied.  Being 
out-of-doors  from  three  to  four  hours  a  day 
is  of  decided  advantage  to  every  nursing 
woman.  If  she  possess  sufficient  intelligence 
to  take  the  baby  for  his  outings,  she  should 
be  allowed  to  do  so.  For  the  comfort  of  the 
family,  it  is  wise  not  to  let  a  wet-nurse  know 
her  full  value.  When  she  feels  that  she  is 
indispensable,  trouble  is  apt  to  follow  from 
one  source  or  another.  It  is  particularly 
necessary,  therefore,  that  babies  that  are 
wet-nursed  should  be  given  one  bottle-feeding 
daily  as  soon  as  they  are  able  to  take  care  of 
it.  The  wet-nurse  will  then  realize  that 
she  can  be  dispensed  with  in  case  of  miscon- 
duct, or  if  she  leaves  with  an  hour's  notice 
the  child  can  be  given  the  bottle  until  another 
nurse  is  secured.  In  the  great  majority  of 


Care  of  the  Breasts  and  Nipples    45 

my  cases  it  has  not  been  necessary  to  con- 
tinue the  wet-nursing  after  the  children  are 
seven  months  of  age,  for  by  this  time  they 
can  usually  be  fed  on  the  bottle.  Of  course, 
unless  her  nursing  proves  unsatisfactory,  a 
wet-nurse  should  not  be  dismissed  at  the 
commencement  of  or  during  the  summer. 

CARE  OF  THE  BREASTS  AND  NIPPLES 

After  nursing  is  well  established  the  baby 
should  be  nursed  at  about  two-hour  intervals 
during  the  day.  From  6  A.M.  to  1 1  P.M.  there 
should  be  nine  nursings.  If  he  sleeps  be- 
tween ii  P.M.  and  6  A.M.  do  not  wake  him. 
One  feeding  at  2.30  A.M.  is  required  by  a  few 
children  up  to  the  third  month ;  the  great 
majority,  however,  do  better  without  it.  Be- 
fore and  after  each  nursing  the  mother's  nip- 
ples should  be  gently  washed  with  a  saturated 
solution  of  boracic  acid,  using  either  clean 
old  linen  or  absorbent  cotton.  The  nipples 
should  be  thoroughly  dried  after  the  washing. 

Nursing  is  often  most  painful  on  account 
of  cracks  and  fissures  in  the  nipples.  These 
are  very  apt  to  occur  if  the  parts  arc  neg- 
lected, and  the  resulting  pain  when  the  child 
nurses  is  unbearable,  necessitating  some- 


46  Care  of  the  Breasts  and  Nipples 


times  the  discontinuance  of  the  breast-feed- 
ing. The  baby  should  never  be  allowed  to 
touch  a  cracked  or  fissured  nipple,  and  a 
nipple-shield  (see  Fig.  2)  should  be  used 
until  the  parts  are  healed.  Some  babies 
take  very  unkindly  to  the  nipple-shield,  and 
often  a  great  deal  of  patience  must  be  exer- 
cised before  they  can  be  taught  its  use.  If 
the  shield  suggested  does  not  answer,  others 
may  be  tried.  The  breast  should  never  be  al- 
lowed to  become  hard  or 
painful.  If  the  child  does 
not  take  enough  to  keep 
the  breasts  soft  a  breast- 
pump  should  be  used  to  re- 
move the  remainder.  For 
this  purpose,  the  so-called 
English  breast-pump  (see 
Fig-  3)  is  the  best.  With 
the  first  rush  of  milk  to  the 
breasts  it  is  often  very  dif- 
FIG.  2.  NIPPLE-SHIELD  ficult  toprevent hard,  pain- 
ful nodules  from  forming  in 
the  glands.  The  free  use  of  the  breast-pump 
and  massage  with  warm  oil,  if  properly  carried 
out,  will  prevent  the  formation  of  an  abscess. 
When  the  breasts  are  large  and  pendulous, 


Care  of  the  Breasts  and  Nipples    47 


a  support  consisting  of  a  bandage  firmly 
applied  around  the  chest  will  often  afford 
much  comfort  and  prevent  serious  trouble. 
In  addition  to  the  use  of  the  nipple-shield, 
the  cracked  nipple  should  be  washed  with  a 
saturated  boracic-acid 
solution  after  each  nurs- 
ing, and  dried,  when  a 
soothing  ointment  may 
be  applied  on  old  linen; 
such  an  ointment,  com- 
posed of  ichthyol  fifteen 
grains,  vaseline  one-half 
ounce,  oxide-of-zinc  oint- 
ment one-half  ounce, 
has  given  most  satis- 
factory results.  The 
ointment  should  be  care- 
fully removed  with  warm 
sweet-oil  and  the  nipple 
washed  in  alcohol  before 
the  next  nursing.  When 
the  fissures  are  healed, 
the  nursing  may  be  resumed,  allowing  the 
child  for  a  few  days  to  take  the  nipple  every 
second  or  third  nursing,  thus  gradually 
accustoming  the  nipples  to  the  rough  usage. 


FIG.   3.      ENGLISH  BREAST- 
PUMP 


48  Weaning 

WEANING 

When  is  the  nursing  baby  to  be  given  other 
food,  or  how  long  can  the  breast  be  relied 
upon  to  furnish  the  child  its  sole  nourish- 
ment? If  the  mother,  unassisted,  is  able  to 
nourish  her  infant  completely  until  it  is  seven 
months  of  age,  she  is  doing  remarkably  well. 
There  are  very  few  nursing  mothers  who  can 
pass  that  period  without  assistance.  Per- 
haps one  or  two  bottle-feedings  a  day  may 
suffice.  In  many  cases  the  milk  will  fail 
about  the  seventh  month,  and  absolute  wean- 
ing be  necessary.  Granting,  however,  that 
the  child  is  thriving  on  the  breast  alone,  or 
doing  satisfactorily  on  the  breast  with  only 
two  daily  feedings,  at  what  age  should  the 
weaning  take  place?  I  have  known  just  one 
mother  out  of  several  thousand  who  could 
nurse  her  child  to  the  child's  advantage  after 
twelve  months  had  passed.  I  have  seen 
many  pronounced  cases  of  malnutrition  and 
rickets  due  directly  to  prolonged  nursing. 
Indigestion  and  diarrhoea  are  often  the  out- 
come of  prolonged  breast-feeding. 

The  weaning  in  health  should  begin  not 
later   than   the   twelfth   month.     It   is   best 


Weaning  49 

accomplished  gradually  by  substituting 
bottle-feeding  for  nursing,  giving  only  one 
bottle  the  first  day,  two  the  second,  three  the 
third,  and  so  on  until  in  a  week  or  ten  days 
weaning  is  complete.  In  case  the  child  is 
ill  we  may  be  obliged  to  wean  at  once, 
when  bottle-feeding  is  substituted  for  the 
breast,  but  the  milk  formula  corresponding 
to  his  age  should  not  be  given.  To  a  child 
six  months  of  age  give  the  three-months' 
formula;  a  child  nine  months  of  age  should 
receive  the  six-months'  formula.  A  gradual 
increase  to  the  formula  suggested  for  a  child 
the  age  of  the  patient  may  be  made  if  all 
goes  well.  After  the  ninth  month  it  is  often 
possible  to  feed  from  a  cup,  which  is  then  to 
be  preferred  to  bottle-feeding  as  a  substi- 
tute for  the  breast. 

Care  of  breasts  during  weaning. — When  the 
breast-feeding  is  carried  on  the  usual  length 
of  time — from  nine  to  twelve  months, — the 
process  of  weaning  ordinarily  causes  little  or 
no  discomfort.  All  that  is  usually  required 
is  to  press  out  enough  of  the  milk  to  relieve 
the  patient  as  often  as  the  breast  becomes 
painful,  which  may  not  be  more  than  two  or 
three  times  a  day.  When  the  weaning  is 


50         The  Selection  of  Milk 

necessarily  abrupt,  no  little  discomfort  may 
result.  If  there  is  a  free  flow  of  milk,  which 
is  apt  to  be  the  case  when  the  weaning  must 
take  place  in  the  early  nursing  period,  tightly 
bandaging  the  breasts  is  required.  When 
localized  hardened  areas  occur  in  the  glands, 
they  should  be  massaged  until  softened,  and 
the  bandage  reapplied  and  woni  until  the 
secretion  ceases.  When  the  weaning  can 
more  gradually  be  done,  the  best  way  is  to 
give  one  less  nursing  every  second  or  third 
day  until  only  two  are  given.  After  this  has 
been  practised  for  one  week,  these  also  can 
be  discontinued.  In  cases  where  sudden 
weaning  is  required,  a  saline  laxative,  such 
as  citrate  of  magnesia  or  Rochelle  salts, 
should  be  given  every  day  for  five  days' — 
sufficient  to  produce  two  or  three  watery 
evacuations  daily.  In  the  meantime  the 
mother  should  abstain  from  fluids  of  all  kinds 
up  to  the  point  of  positive  discomfort. 

THE  SELECTION  OF  MILK 

The  selection  of  the  milk  on  which  the  baby 
is  to  live  is  a  matter  of  no  little  importance. 
There  is  a  vast  difference  in  the  quality  and 


The  Selection  of  Milk          51 

cleanliness  of  the  milks  on  the  market.  Too 
many  mothers  look  upon  all  milk  as  being  of 
uniform  value  because  it  all  has  a  similar 
appearance.  While  the  general  character  of 
the  milk  sold  has  improved  greatly  as  regards 
cleanliness  during  the  past  few  years,  a  great 
deal  of  that  used  at  the  present  time  is  unfit 
for  food  for  a  baby.  New  York  City  mothers 
should  insist  that  the  milk  used  be  bottled 
and  sealed  at  the  farm,  and  also  insist  that  it 
be  certified  by  the  New  York  Milk  Com- 
mission. Milk  if  properly  produced  is  ex- 
pensive; it  cannot  be  sold  for  six  or  eight 
cents  a  quart,  and  mothers  will  have  to  pay 
more  than  this  if  they  get  a  suitable  article. 
The  most  expensive  milk  will,  as  a  rule,  be 
found  safest  for  use. 

When  certified  milk  or  one  of  the  higher- 
class  milks  is  not  obtainable,  as  is  the  case 
with  those  whose  home  is  in  the  country,  and 
for  the  families  from  the  larger  cities  who 
spend  the  summer  months  in  more  or  less 
remote  country  districts,  the  matter  of  secur- 
ing a  safe  milk  is  of  vital  importance.  Tho 
average  farmer  is  notoriously  careless  in  the 
handling  of  milk,  and  in  the  country  dis- 
tricts, where  the  milk  supply  should  be  the 


52          The  Selection  of  Milk 

best,  it  is  often  as  bad  as  can  well  be  imagined. 
In  the  country,  where  the  milk  is  furnished 
by  the  farmer  direct,  a  special  arrangement 
may  be  made,  by  which  he  agrees:  that  the 
cow's  belly,  udder,  and  teats  shall  be  wiped 
off  with  a  damp  cloth  before  milking;  that 
the  milker's  hands  shall  be  washed  before 
milking;  that  the  few  jets  of  the  fore-milk 
shall  be  thrown  away ;  and  that  as  soon  as 
the  milk  is  drawn  it  shall  be  strained  through 
absorbent  cotton  into  a  quart  milk  bottle, 
suitably  corked,  and  placed  in  a  pail  of 
cracked  ice.  The  cracked  ice  and  the  ab- 
sorbent cotton,  are,  of  course,  furnished  by 
the  consumer.  For  the  extra  trouble  the 
farmer  receives  from  twrelve  to  twenty  cents 
a  quart  for  the  milk.  The  improved  milk- 
pail  with  the  small  top  opening  insures  a 
much  cleaner  milk,  as  it  offers  much  less 
opportunity  for  droppings  to  fall  into  it  dur- 
ing the  milking. 

For  those  who  have  country  homes  and 
who  can  control  their  milk-supply,  the  above 
precautions  may  be  carried  out  to  the  letter. 
By  such  careful  control  of  the  home  product, 
and  by  the  use  of  milk  from  those  dairies 
only  which  observe  the  above  precautions, 


The  Nursing-Bottle  and  Nipple    53 

the  acute  digestive  disorders  of  summer 
among  my  patients  are  rendered  a  very  un- 
usual occurrence.  These  precautions,  with 
the  knowledge  of  the  mother  or  nurse  as  to 
what  to  do  at  the  first  sign  of  a  digestive 
disorder,  will  reduce  the  number  of  the  so- 
called  summer  diarrhcea  cases  to  a  very 
insignificant  figure. 

A  further  and  very  essential  requirement 
is  that  all  cows  used  for  furnishing  milk  to 
infants  be  tested  for  tuberculosis  every  six 
months. 

THE  NURSING-BOTTLE  AND  NIPPLE 

There  are  two  requirements  that  a  nursing- 
bottle  must  fulfil:  It  must  have  a  capacity 
sufficient  for  one  full  feeding,  and  it  must  be 
so  constructed  as  to  be  readily  cleansed. 
The  oval  bottle  (Fig.  4)  with  rounded  edges 
answers  best.  These  may  be  obtained  in 
sizes  of  from  three  to  nine  ounces.  As  many 
bottles  are  needed  as  there  are  feedings  in 
twenty-four  hours.  The  bottles  should  be 
boiled  once  a  day,  scrubbed  with  a  stiff  brush, 
with  hot  borax  water,  and  remain  in  the 
borax  water  until  needed.  Two  teaspoon- 


54 


Artificial  Feeding 


fuls  of  borax  to  a  pint  of  water  is  the  strength 
usually  used.  Before  using,  bottles  should 
be  rinsed  in  plain  boiled  water.  The  straight, 
black  nipple  (Fig.  4)  is  also  pre- 
ferred, for  the  reason  that  it 
can  be  turned  inside  out  and 
easily  cleansed.  A  nipple  which 
cannot  be  turned  should  never 
be  used.  After  using,  a  nip- 
ple should  be  turned  and  scrub- 
bed with  a  stiff  brush  and  borax 
water1 — a  tablespoonful  of  bo- 
rax to  a  pint  of  water.  When 
not  in  use,  the  nipple  should 
be  kept  in  borax  water.  Be- 
fore placing  it  on  the  bottle 
it  should  be  rinsed  in  boiled 
water.  The  nipples  should  be 
boiled  once  a  day.  The  blind 

nipples— thOSC   without  holCS" 

are    the   best.      Holes   of   the 
required    size    may    be   made 
with  a  red-hot  cambric  needle. 

ARTIFICIAL  FEEDING 

BOTTLE-FEEDING 

When  it  is  decided  that  the  child  will  have 


Artificial  Feeding  55 

to  be  nourished  by  other  means  than  the 
breast,  we  are  obliged  to  furnish  a  suitable 
substitute  for  the  mother's  milk  which  the 
child  has  a  right  to  demand.  In  our  selec- 
tion we  must  be  guided  by  Nature  and  fur- 
nish a  food  that  will  correspond  as  closely  as 
possible  to  the  mother's  milk.  This  can  be 
done  only  by  the  use  of  cows'  milk  properly 
prepared  and  diluted.  Proprietary  foods 
and  condensed  milk  furnish  very  poor  sub- 
stitutes, as  will  be  seen  under  their  respective 
headings  elsewhere.  Cows'  milk  differs  from 
mother's  milk  in  its  most  important  con- 
stituents. Good  cows'  milk  contains  pri- 
marily 3.50  to  4  per  cent,  of  fat,  3.50  to  4  per 
cent,  of  proteid,  and  4  to  5  per  cent,  of  sugar. 
Mother's  milk  on  the  other  hand  contains 
3.5  to  4  per  cent,  of  fat,  1.5  percent,  of  proteid, 
and  7  per  cent,  of  sugar.  It  will  be  seen  that 
cows'  milk  contains  more  proteid  (curd)  and 
less  sugar  than  is  contained  in  mother's  milk. 
We  must  endeavor  to  make  the  proportion 
of  the  important  constituents  of  cows'  milk— 
the  fat,  proteid,  and  sugar — correspond  to 
that  of  mother's  milk.  This  has  given  rise 
to  the  term  mcdificd  milk.  Cows'  milk  is 
made  to  correspond  to  that  of  the  mother  by 


56  Artificial  Feeding 

diluting  it  with  water  to  reduce  the  proteid, 
and  then  by  adding  cream  and  milk-sugar  to 
bring  up  the  fat  and  sugar  to  the  required 
strength. 

The  term  -modified  milk  is  not  a  good  one, 
for  the  term  "modified"  does  not  cover  all 
that  is  done  in  rendering  cows'  milk  a  suitable 
diet,  that  is,  changing  it  to  correspond  to 
mothers'  milk.  We  would  have  very  little 
success  in  infant  feeding  if  this  were  all  we 
did.  The  milk  must  be  adapted  to  a  child's 
age  and  peculiarities,  so  that  the  term  adapted 
milk  expresses  far  better  what  we  wish  to  ac- 
complish. In  adapting  milk  to  an  infant,  we 
must  remember  that  cows'-milk proteid  (curd) 
is  more  difficult  to  digest  than  the  proteid  of 
mothers'  milk,  and  that  frequently  a  smaller 
amount  of  fat  must  be  given  than  is  contained 
in  mothers'  milk.  Particularly  must  these 
precautions  be  observed  in  the  very  young 
and  delicate.  The  gravest  error,  and  one 
most  frequently  made  in  cows'-milk  feeding, 
is  that  of  giving  the  food  too  strong,  at  the 
beginning.  In  consequence,  the  digestive 
organs  are  overtaxed,  the  child  vomits,  has 
colic,  suffers  from  constipation  or  diarrhoea, 
and,  of  course,  cannot  thrive;  cows'  milk  is 


Artificial  Feeding  57 

therefore  discarded  because  it  did  not  agree 
with  the  baby,  while  it  was  not  the  milk  but 
the  way  it  was  given  that  was  at  fault.  In 
the  feeding  formulas  given  below,  the  milk 
is  adapted  to  the  various  ages  of  infancy  and 
not  to  the  child's  condition,  as  that  would 
obviously  be  impossible.  These  formulas 
will  be  found  suitable  for  average  infants  in 
fair  health.  In  the  matter  of  feeding,  every 
child  is  a  law  unto  himself  and  he  must  be 
fed  individually.  For  some  babies  the  form- 
ulas suggested  will  not  answer  at  all.  One 
six-months'  child  may  require  the  nine- 
months'  formula,  while  another  may  be  able 
to  take  only  the  three-months'  formula.  All 
babies  of  the  same  age  or  weight  must  not  be 
expected  to  thrive  on  food  of  exactly  the 
same  strength. 

It  is  the  duty  of  the  physician  to  adapt  the 
milk  to  the  patient's  digestive  capacity  by 
giving  to  each  the  required  proportion  of  fat, 
proteids,  and  sugar.  The  signs  of  successful 
bottle-feeding  are  the  same  as  of  successful 
breast-feeding:  comfort,  sleep,  and  an  aver- 
age gain  in  weight  of  not  less  than  four  ounces 
a  week.  There  should  be  two  or  three  yellow 
.stools  dailv. 


58  Artificial  Feeding 

The  signs  of  unsuccessful  feeding  are  vom- 
iting, discomfort  after  feeding,  habitual  colic, 
green,  undigested  stools,  and  loss,  or  a  very 
slight  gain,  in  weight.  A  very  few  children 
cannot  take  cows'  milk  in  any  form.  In  this 
class  belong  those  wrho  have  been  badly  man- 
aged. They  have  taken  cows'  milk  loo 
strong  or  otherwise  improperly  adapted. 
They  may  have  undergone  a  series  of  hys- 
terical changes  with  various  proprietary  meal 
foods  in  the  hope  that  something  might  be 
found  which  would  agree  with  them  and  on 
which  they  might  thrive. 

In  some  cases  cows'  milk  of  any  strength 
produces  colic  and  vomiting  or  more  often 
diarrhoea.  These  difficult  feeding  cases, 
whether  the  result  of  the  delicate  or  peculiar 
condition  of  the  child  per  sc  or  of  improper 
feeding,  require  the  greatest  patience  on  the 
part  of  the  physician  and  mother.  Many  of 
these  cases  must  be  seen  by  the  physician 
every  day  for  weeks  before  the)'  can  be 
brought  to  take  a  suitable  diet.  Milk  in 
some  must  be  temporarily  discarded  and 
substitutes,  such  as  whey,  diluted  cream, 
barley-water,  broths,  or  malt  soups,  have  to 
be  used.  After  a  short  time  a  von-  small 


Artificial  Feeding 


59 


amount  of  milk  may  be  added  to  the  substi- 
tute which  has  been  found  best  to  agree. 
Should  the  milk  again  cause  disturbance, 
condensed  milk' — one-half  to  one  teaspoon- 
ful — may  be  given  with  barley  water,  in- 
creasing the  amount  of  condensed  milk 
gradually  if  it  is  found  to  agree.  A  wet- 
nurse  is  almost  indis- 
pensable in  some  of 
these  cases. 

Preparation  of  food. 
— One  or  two  quart 
bottles  of  the  best 
milk  obtainable  are 
required  daily,  depend- 
ing upon  the  formula 
used.  The  milk,  which 
is  delivered  at  six  or 
seven  o'clock  in  the 
morning,  is  at  once 
placed  in  a  refrigerator 
(at  50°  F.  or  lower),  where  it  remains  for 
a  few  hours,  until  it  is  convenient  to  pre- 
pare the  food.  If  the  milk  and  cream 
formulas  are  used  (page  61),  one  bottle 
furnishes  the  milk,  the  other  the  cream. 
The  bottle  which  is  to  furnish  the  milk  must 


TI1K  CIIAl'IN  DII'PKK 


Oo 


Artificial  Feeding 


be  well  shaken  before  using,  so  as  thoroughly 
to  mix  the  milk  and  cream.     In  the  event  of 
using  the  top-milk  formulas  (page  65),  one 
bottle    daily    only    is    required    for    several 
months.     Skimmed    milk    should    never    be 
given  to  an  infant  excepting  as  ordered  by  a 
physician.     Boiled  water  should  always  be 
used.      The  milk-sugar 
should   be  dissolved  in 
hot  water  before   mix- 
ing   with    the    milk   or 
cream.      The  cream   at 
the   top   of    the    bottle 
is    known   as   "  gravity 
cream."      It  should  not 
be  poured  off  nor  should 
the   milk    be    siphoned 
from     under    it.      The 
same    rule     applies    in 
using  top  milk  (page  65) . 
The  Chapin  dipper   (see 
Figure  5)   furnishes  the 

best  means  of  removing  the  cream  or  in 
obtaining  top  milk.  The  upper  portion 
of  the  milk  in  the  bottle  is  richer  in  fat 
than  that  lower  down,  therefore  if  only 
the  upper  dipper  or  two  is  removed  it. 


KIG.    6. 


ONE    PINT    GRAD- 
UATE 


Artificial  Feeding  61 

gives  a  mixture  too  rich  in  fat.  Such  he- 
ing  the  case,  no  matter  how  little  cream 
or  top  milk  may  be  required,  all  should  be 
removed  from  the  bottle  as  indicated  in 
the  formula  used  and  placed  in  a  clean  pint 
graduate  (see  Fig.  6),  which  is  to  be  used 
for  all  measuring  purposes,  and  stirred  a 
trifle  to  make  it  of  uniform  strength.  If  the 
required  amount  of  cream  or  top  milk  cannot 
be  obtained  from  one  bottle,  another  pint  or 
quart  of  milk  should  be  purchased,  but  cream 
purchased  as  such  should  never  be  used  for 
infant  feeding. 

Milk  and  cream  feeding. — The  following 
formulas  for  the  different  ages  may  be  found 
useful  for  well  babies : 

From  the  first  to  the  third  day: 

Milk-sugar J    ounce. 

Water 16     ounces. 

One-fourth  to  one  ounce  every  two  or  three 
hours. 

From  the  third  to  the  tenth  day: 

Gravity  cream J  ounce. 

Milk 3     ounces. 

Milk-sugar i     ounce. 

Lime-water I  ounce. 

Water  to  make  .  .16     ounces. 


62  Artificial  Feeding 

Ten  feedings  in  twenty-four  hours;  i   to   ij 
ounces  at  each  feeding. 

From  the  tenth  to  the  twenty-first  day: 

Gravity  cream ij  ounces. 

Milk 5  ounces. 

Milk-sugar i  £  ounces. 

Lime-water ij  ounces. 

Water  to  make 24    ounces. 

Ten  feedings  in  twenty-four  hours;   ij  to   2 
ounces  at  each  feeding. 

From  the  third  to  the  sixth  week: 

Gravity  cream i\  ounces. 

Milk 8    ounces. 

Milk-sugar 2     ounces. 

Lime-water 2     ounces. 

Water  to  make 32    ounces. 

Nine  feedings  in  twenty-four  hours;   2   to  3 
ounces  at  each  feeding. 

From  the  sixth  week  to  the  third  month: 

Gravity  cream 3  ounces. 

Milk 9  ounces. 

Milk-sugar 2  ounces. 

Lime-water 3  ounces. 

Water  to  make 32  ounces. 


Artificial  Feeding  63 

Eight  feedings  in  twenty-four  hours;  aj  to  4 
ounces  at  each  feeding. 

From  the  third  to  the  fifth  month: 

Gravity  cream 4    ounces. 

Milk 15     ounces. 

Milk-sugar 2%  ounces. 

Lime-water 4    ounces. 

Water  to  make 40    ounces. 

Eight  feedings  in  twenty-four  hours;  4  to  5 
ounces  at  each  feeding. 

From  the  fifth  to  the  seventh  month: 

Gravity  cream 5    ounces. 

Milk 1 8    ounces. 

Milk-sugar 2^  ounces. 

Lime-water 5     ounces. 

Water  to  make 42     ounces. 

Six  to  seven  feedings  in  twenty-four  hours; 
5  to  7  ounces  at  each  feeding. 

After  the  fifth  month  it  is  my  custom  to 
add  from  one  to  three  teaspoonfuls  of  a  cereal 
icily  to  each  feeding.  This  may  be  added  to 
the  milk  mixture  when  it  is  made  in  the 
morning.  Thus,  if  one  tcaspoonful  is  to  be 
<;'ven  at  each  feeding  in  a  case  which  is  get- 


64  Artificial  Feeding 

ting  six  feedings,  six  teaspoonfuls  of  the  jelly 
may  be  added  to  the  entire  quantity. 

From  the  seventh  to  the  ninth  month  : 

Gravity  cream 6    ounces. 

Milk 23     ounces. 

Milk-sugar 2^  ounces. 

Lime-water 6    ounces. 

Water  to  make 48    ounces. 

Five  to  six  feedings  in  twenty-four  hours;  6  to 
8  ounces  at  each  feeding. 

From  the  ninth  to  the  tivelfth  month: 

Gravity  cream 7  ounces. 

Milk 32  ounces. 

Milk-sugar 3  ounces. 

Lime-water 6  ounces. 

Water  to  make 56  ounces. 

Five  to  six  feedings  in  twenty-four  hours; 
7  to  9  ounces  at  each  feeding. 

The  use  of  top  milk  is  preferred  by  many 
as  it  necessitates  the  purchase  of  but  one 
bottle  of  milk  during  the  early  months  of 
life.  Other  than  this  it  possesses  no  ad- 
vantages over  the  milk  and  gravity  cream 
feeding. 


Artificial  Feeding  65 

Top-milk  feeding. — In  using  top  milk  for 
infant  feeding  the  milk  is  allowed  to  stand 
in  a  quart  bottle  at  a  temperature  of  45°  to 
50°  F.  for  the  same  length  of  time  as  when 
gravity  cream  is  desired — five  hours — when 
certain  amounts  from  the  top  of  the  bottle 
are  removed  with  a  Chapin  dipper  (Fig.  5) 
and  diluted  with  different  quantities  of  water 
or  gruel  to  which  sugar  of  milk  and  lime- 
water  are  added.  The  milk  selected  should 
be  the  cleanest  obtainable  from  grade  cows ; 
usually  the  most  expensive  is  the  best.  If 
so-called  "certified  milk"  (page  51)  is  ob- 
tainable, it  should  be  used,  as  this  warrants 
a  cleaner  food  than  that  furnished  by  the 
usual  market  milks. 

From  a  quart  bottle  of  milk  in  which  the 
cream  has  risen,  dip  off  from  the  top  with  a 
Chapin  dipper  sixteen  ounces  and  mix.  From 
average  milk  this  should  contain: 

7.0  per  cent,  fat; 
3.2  per  cent,  sugar; 
3.2  per  cent,  proteid. 

The  following  formulas  are  suggested  for 
the  various  ages  noted: 


66  Artificial  Feeding 

From  the  third  to  the  tenth  day: 

Top  milk 3    ounces. 

Milk-sugar i    ounce. 

Lime-water \  ounce. . 

Water  to  make 16    ounces. 

Ten  feedings  in  twenty-four  hours;  i   to  ij 
ounces  at  each  feeding. 

From  the  tenth  to  the  twenty-first  day: 

Top  milk 6    ounces. 

Milk-sugar ij  ounces. 

Lime-water i£  ounces. 

Water  to  make 24    ounces. 

Ten  feedings  in  twenty-four  hours;  i£  to  2 
ounces  at  each  feeding. 

From  the  third  to  the  sixth  week: 

Top  milk 10    ounces. 

Milk-sugar 2    ounces. 

Lime-water -2.\  ounces. 

Water  to  make 32    ounces. 

Nine  feedings  in  twenty-four  hours;   2   to   3 
ounces  at  each  feeding. 

From  the  sixth  week  to  the  third  month: 
Top  milk 12     ounces. 


Artificial  Feeding  67 

Milk-sugar 2    ounces. 

Lime-water 3    ounces. 

Water  to  make 32    ounces. 

Eight  feedings  in  twenty-four  hours;  z\  to  4 
ounces  at  each  feeding. 

From  the  third  to  the  fifth  month: 

Top  milk 1 8    ounces. 

Milk-sugar 2^  ounces. 

Lime-water 4    ounces. 

Water  to  make 40    ounces. 

Eight  feedings  in  twenty-four  hours;  4  to  5 
ounces  at  each  feeding. 

From  the  fifth  to  the  seventh  month: 

After  this  age  two  bottles  of  milk  are  required, 
1 6  ounces  being  taken  from  the  top  of  each 
bottle  and  mixed.  The.  same  rule  applies  here 
as  to  the  addition  of  cereals  found  on  page  63. 

Top  milk 21     ounces. 

Milk-sugar 2\  ounces. 

Lime-water. 5    ounces. 

Water  to  make 42     ounces. 

Six  to  seven  feedings  in  twenty-four  hours; 
5107  ounces  at  each  feeding. 


68  Artificial  Feeding 

From  the  seventh  to  the  ninth  month: 

Top  milk 27    ounces. 

Milk-sugar 2\  ounces. 

Lime-water 6    ounces. 

Water  to  make 48    ounces. 

Five   to   six   feedings   in   twenty-four    hours; 

6  to  8  ounces  at  each  feeding. 

From  the  ninth  to  the  twelfth  month: 

Top  milk 35  ounces. 

Milk-sugar 3  ounces. 

Lime-water 6  ounces. 

Water  to  make 56  ounces. 

Five   to   six   feedings   in   twenty-four   hours; 

7  to  9  ounces  at  each  feeding. 

After  the  twelfth  month,  plain  cows'  milk 
may  be  given  with  the  cereal  jelly  in  addi- 
tion to  the  other  articles  of  diet  suggested  for 
a  child  one  year  old.  (See  page  73.) 

The  cereal  jellies  are  made  by  boiling  the 
cereal  selected  for  three  hours.  It  will  be 
noticed  that  considerable  latitude  is  allowed 
as  to  the  amount  of  food  which  is  to  be  given 
at  one  feeding.  This  is  because  of  the  differ- 
ence in  the  capacity  of  individual  children. 


Artificial  Feeding  69 

After  the  third  month  the  midnight  feeding 
should  be  discontinued.  Seven  feedings  will 
be  sufficient,  the  first  at  6  A.M.  and  the  last  at 
10.30  or  ii  P.M.  Between  11  P.M.  and  6  A.M. 
the  child  should  sleep.  Babies  are  easily 
broken  from  the  night  bottle  by  substituting 
a  bottle  of  boiled  water  or  a  milk  mixture 
greatly  diluted  with  water.  The  child  soon 
discovers  that  this  is  not  worth  waking  for. 
As  a  result  of  a  full  night's  rest  the  digestive 
organs  are  better  able  to  do  their  work,  the 
appetite  is  increased,  and  a  larger  amount  of 
food  may  be  given  at  each  feeding. 

The  foregoing  formulas  will  be  found  use- 
ful for  the  majority  of  average  well  babies. 
Those  with  pronounced  digestive  peculiari- 
ties should  have  the  food  especially  adapted. 

When  the  milk  does  not  agree  the  cause 
must  be  discovered.  The  food  as  a  whole 
may  be  too  strong,  when  there  will  be  indi- 
gestion and  colic,  and  possibly  diarrhoea  and 
vomiting.  If  the  food  contains  too  much 
cream  there  will  be  looseness  of  the  bowels, 
and  colicky  stools,  with  considerable  strain- 
ing; there  is  apt  to  be  regurgitation  also. 
The  sugar  is  rarely  a  cause  of  trouble,  an 
indication  of  excess  being  the  eructation  ot 


70  Artificial  Feeding 

gas  and  a  regurgitation  of  sour,  watery 
material.  It  is  comparatively  rare,  how- 
ever, for  the  fat  and  sugar  to  cause  any  dis- 
turbance if  they  are  given  with  any  degree 
of  intelligence;  but  the  proteid — the  curd- 
forming  element  in  cows'  milk1 — often  gives 
us  no  end  of  trouble.  Many  infants,  as  pre- 
viously stated,  are  able  to  digest  only  a  very 
weak  cows'-milk  proteid;  consequently,  at 
the  beginning  of  cows'-milk  feeding,  when, 
as  is  often  the  case,  too  much  milk  is  used, — 
too  strong  a  food  given, — the  result  is  always 
disastrous.  This,  with  too  frequent  feeding 
and  night  feeding,  comprise  the  chief  errors 
made  in  cows'-milk  feeding;  in  fact,  they 
are  the  cause  of  more  bottle-feeding  failures 
than  all  other  factors  combined.  Excess  of 
cows'-milk  proteid  is  the  cause  of  habitual 
colic,  and  is  an  important  element  in  habitual 
constipation.  Chronic  indigestion,  as  shown 
by  vomiting  and  undigested  green  stools,  is 
most  frequently  due  to  this  cause.  We 
frequently  see  children  who  cannot  take 
cows'  milk  in  any  form;  they  must  be  given 
cream  diluted  either  with  plain  boiled  water 
or  with  a  cereal  water  to  which  milk-sugar  or 
cane-sugar  has  been  added. 


Sterilization  of  Milk  71 

STERILIZATION    AND  PASTEURIZATION 
OF  MILK 

Sterilized  milk  is  rarely  used  at  the  present 
time  in  routine  feeding.  Milk  is  said  to  be 
sterilized  when  it  has  been  heated  to  the 
boiling  point,  212°  P.,  and  kept  at  this  point 
for  thirty  minutes. 

Pasteurized  milk  is  milk  heated  to  155°  F. 
and  kept  at  this  temperature  for  thirty 
minutes.  In  heating  the  milk  we  have  two 
objects  in  view:  to  kill  the  harmful  micro- 
organisms which  it  may  contain,  and  to  keep 
the  milk  sweet  for  a  longer  time  than  would 
otherwise  be  possible.  The  degree  of  heat 
to  which  the  milk  is  subjected  should  depend 
upon  the  season  of  the  year,  the  source  of 
the  supply,  the  age  of  the  milk,  and  the  diges- 
tive capacity  of  the  child.  The  more  the 
milk  is  heated  the  more  difficult  of  digestion 
it  becomes,  and  the  more  liable  it  is  to  pro- 
duce constipation;  so  that,  other  things  being 
equal,  the  less  we  heat  the  milk  the  better 
the  nourishment  we  fumish  to  the  child.  In 
country  districts  where  the  cows  are  known 
to  be  healthy,  and  the  milk  clean  and  fresh, 
heating  is  unnecessary.  In  cities  and  large 


72 


Sterilization  of  Milk 


towns,  where  the  source  of  the  milk  may  be 
unknown,  and  where  it  is  from  twenty-four 
to  thirty-six  hours  old  when  it  reaches  the 
consumer,  heating  to  a  moderate  degree  is  a 
safe  procedure  at  any  time  of  the  year.  Pas- 
teurizing the  milk  kills  most  of  the  dangerous 
germs  without  materially  affecting  the  diges- 


FIG.  7.   FREEMAN  PASTEURIZER  WITH  BOTTLE  RACK 
REMOVED 

tibility,  or  changing  the  taste  of  the  milk. 
Among  the  intelligent  and  cleanly  I  advise 
the  pasteurization  of  milk;  among  the  igno- 
rant poor  and  the  careless, — such  as  we  fre- 
quently see  in  out-patient  work,' — the  milk 
should  be  boiled,  particularly  during  the  hot 


Feeding  after  the  First  Year     73 

months.  The  pasteurization  of  milk  is  best 
accomplished  by  the  use  of  the  Freeman 
Pasteurizer  (see  Fig.  7).  Directions  for  use 
are  furnished  with  the  Pasteurizer. 

If  for  any  reason  the  Freeman  Pasteurizer 
cannot  be  used,  the  milk  may  be  heated  in  a 
double  boiler.  If  this  is  not  at  hand  an  ordi- 
nary agate  basin  may  be  used.  The  vessel 
should  be  placed  over  a  slow  fire,  with  a  milk 
thermometer  held  in  the  mixture.  When 
the  thermometer  registers  170°  P.,  remove  the 
milk  from  the  fire  and  pour  it  into  as  many 
bottles  as  there  are  feedings  in  the  twenty- 
four  hours.  Absorbent  cotton  should  be 
used  for  stoppers.  The  bottles  should  be 
cooled  rapidly  by  placing  them  in  cold  water. 
The  Freeman  Pasteurizer  should  always  be 
used  if  possible,  for  the  reason  that  it  saves 
much  trouble,  the  temperature  to  which  the 
milk  is  heated  is  uniform,  it  requires  no 
manipulation  of  the  milk  after  it  has  been 
prepared  and  heated,  and  there  are  no 
chances  of  the  contamination  of  the  milk 
from  the  air. 

FEEDING  AFTER  THE  FIRST  YEAR 

At  the  completion   of  the  twelfth   month. 


74      Feeding  after  the  First  Year 

the  average  well-regulated  baby  should  be 
weaned,  and  other  nourishment  given.  If 
bottle-fed,  he  should  receive  more  than  the 
milk  and  cereals,  with  which  most  children 
are  fed.  The  food  suitable  for  the  second 
year  of  life  and  the  method  of  its  preparation 
and  administration  are  subjects  upon  which 
the  masses  are  most  profoundly  ignorant. 
A  few  children  at  this  period  of  life  are  under- 
fed, but  the  great  majority  are  overfed,  and 
carelessly  given,  at  improper  intervals,  un- 
suitable food,  wretchedly  cooked.  Summer 
diarrhoea  finds  its  greatest  number  of  victims 
among  those  children  over  twelve  months 
of  age  who  have  been  carelessly  fed.  The 
dreaded  "second  summer"  robs  many  homes 
because  of  ignorant  or  careless  parents.  The 
second  summer  managed  properly  is  hardly 
more  dangerous  than  any  other  summer 
during  the  early  years  of  a  child's  life.  It  is 
almost  a  universal  custom  when  the  child  is 
weaned  or  given  something  other  than  a  milk 
diet,  to  allow  him  "tastes"  from  the  table. 
Very  often  these  tastes  comprise  the  entire 
dietary  of  the  adult.  Milk  is  oftentimes  the 
only  suitable  article  of  diet  that  is  given. 
Afterward  not  only  is  the  other  food  selected 


Feeding  after  the  First  Year      75 

unsuitable,  but  it  is  given  irregularly,  and 
supplemented  by  crackers  kept  on  hand  for 
use  between  meals.  During  the  hot  months 
the  gastro-intestinal  tract  is  less  able  to  bear 
such  abuse  and  the  child  becomes  ill.  Usually 
when  the  twelfth  month  is  completed  I  give 
the  mother  a  diet  schedule,  with  instructions 
to  begin  gradually  with  the  articles  allowed, 
in  order  to  test  the  child's  ability  to  digest 
them.  Every  new  article  of  food  should  be 
carefully  prepared  and  given  at  first  in  very 
small  quantities.  All  meals  are  to  be  given 
regularly,  with  nothing  between  meals.  With 
many  children  this  expansion  of  the  diet  list 
is  attended  with  considerable  difficulty. 
They  are  thoroughly  satisfied  with  the  milk, 
and  refuse  all  other  forms  of  nourishment. 
In  such  cases  time  and  patience  are  neces- 
sary at  the  feeding  time.  The  more  solid 
articles  of  diet  should  be  given  first,  and  the 
milk  kept  in  the  background. 

Among  the  underfed  seen  at  this  period  of 
life  are  those  who  were  nursed  too  long  or 
those  who  were  kept  for  too  long  a  time  upon 
an  exclusive  milk  diet.  A  great  majority 
of  the  cases  of  malnutrition  of  the  second 
year  are  seen  in  the  exclusively  milk-fed. 


76      Feeding  after  the  First  Year 

They  are  pale,  soft,  flabby,  badly  nourished 
children. 

The  following  is  a  diet  schedule  which  I 
have  employed  for  several  years.  Each 
mother  is  instructed  to  select,  from  the  foods 
allowed,  a  suitable  meal. 

From    the    twelfth     to"    the    fifteenth    month: 
five  meals  daily. 

7  A.M.  Oatmeal,  barley,  or  wheat  jelly. 
one  to  two  tablespoonfuls,  in  eight  ounces 
of  milk.  (The  jelly  is  made  by  cooking  the 
cereal  for  three  hours  the  day  before  it  is 
wanted  and  straining  through  a  colander.) 
Stale  bread  and  butter  or  zwieback  and 
butter. 

9  A.M.     The  juice  of  an  orange. 

ii  A.M.  Scraped  rare  beef,  one  to  three 
teaspoonfuls  mixed  with  an  equal  quantity 
of  bread-crumbs  and  moistened  with  beef- 
juice.  Or  a  soft-boiled  egg  mixed  with  stale 
bread-crumbs ;  a  piece  of  zwieback,  and  a 
half-pint  of  milk. 

(Scraped  beef  is  best  obtained  from  round 
steak,  cut  thick  and  broiled  over  a  brisk  fire 
sufficientlv  to  sear  the  outside.  The  steak 


Feeding  after  the  First  Year      77 

is  then  split  with  a  sharp  knife  and  the  pulp 
scraped  from  the  fibre.) 

3  P.M.  Beef,  chicken,  or  mutton  broth 
with  rice  or  stale  bread  broken  into  the  broth. 
Six  ounces  of  milk,  if  wanted.  Stale  bread 
and  butter  or  zwieback  and  butter.  Many 
children  at  the  above  age  will  take  and  digest 
apple  sauce  and  prune  pulp ;  when  these  are 
given  milk  should  be  omitted. 

6  P.M.     Two  tablespoonfuls  of  cereal  jelly 
in  eight  ounces  of  milk ;  a  piece  of  zwieback. 
Stale    bread    and    butter    or    Huntley    and 
Palmer  breakfast  biscuit. 

10  P.M.  A  tablespoonful  of  cereal  jelly  in 
eight  ounces  of  milk. 

From   the  fifteenth  to   the   eighteenth   month: 
four  meals  daily. 

7  A.M.     Oatmeal,  hominy,  commeal,  each 
cooked  three  hours  the  day  before  they  are 
used.     When  the  cooking  is  completed  the 
cereal  should  be  of  the  consistency  of  a  thin 
paste.     This  is  strained  through  a  colander 
which  upon  cooling  will  form  a  mass  of  jelly- 
like  consistency.     Of  this  give  two  or  three 
tablespoonfuls  served  with  milk  and  sugar  or 


78      Feeding  after  the  First  Year 

butter  and  sugar  or  butter  and  salt.  Eight 
to  ten  ounces  of  milk  as  a  drink.  Zwieback 
or  toast. 

9  A.M.     The  juice  of  one  orange. 

ii  A.M.  A  soft-boiled  egg  mixed  with 
stale  bread-crumbs,  or  one  tablespoonful  of 
scraped  beef  mixed  with  stale  bread-crumbs 
and  moistened  with  beef-juice.  A  drink  of 
milk.  Zwieback  or  bran  biscuit,  or  stale 
bread  and  butter. 

3  P.M.  Mutton,  chicken,  or  beef  broth 
with  rice  or  with  stale  bread  broken  in  the 
broth.  Custard,  cornstarch,  plain  rice  pud- 
ding, junket,  ste\ved  prunes,  baked  apple, 
or  apple  sauce. 

6  P.M.     Farina,  cream  of  wheat,  wheatena 
(each  cooked  two  hours).     Give  from  one  to 
three  tablespoonfuls  served  with  milk   and 
sugar  or  butter  and  sugar  or  salt  and  butter. 
Drink  of  milk.     Zwieback  or  stale  bread  and 
butter. 

From  the  eighteenth  to  the  twenty-fourth  month  : 
jour  meals  daily. 

7  A.M.     Cornmeal,  oatmeal,  hominy  (pre- 
pared   as    in    the    above    schedule).     Serve 


Feeding  after  the  First  Year      79 

with  butter  and  sugar  or  milk  and  sugar  or 
butter  and  salt.  A  soft-boiled  egg  every 
two  or  three  days.  Hashed  chicken  on  toast 
occasionally.  A  drink  of  milk.  Bran  bis- 
cuit and  butter,  or  stale  bread  and  butter. 

9  A.M.     The  juice  of  one  orange. 

ii  A.M.  Rare  beef,  minced  or  scraped, 
the  heart  of  a  lamb  chop,  finely  cut.  Chicken. 
Spinach,  asparagus  tips,  squash,  strained 
stewed  tomatoes,  stewed  carrots,  mashed 
cauliflower.  Baked  apple  or  apple  sauce. 
A  drink  of  milk.  Stale  bread  and  butter. 

After  the  twenty-first  month,  baked  po- 
tato and  well-cooked  string  beans  may  be 
given. 

2.30  P.M.  Chicken,  beef,  or  mutton  broth 
with  rice  or  with  stale  bread  broken  into  the 
broth.  Custard,  cornstarch,  or  plain  rice 
pudding,  junket,  stewed  prunes.  A  drink 
of  milk.  Bran  biscuit  and  butter  or  stale 
bread  and  butter. 

6  P.M.  Farina,  cream  of  wheat,  wheatena 
(each  cooked  two  hours).  Give  from  one  to 
three  tablespoonfuls  served  with  milk  and 
sugar  or  butter  and  sugar  or  salt  and  butter. 
Drink  of  milk.  Zwieback  or  stale  bread  and 
butter. 


8o     Feeding  after  the  First  Year 

From  the  second  to  the  third  year:  three  meals 
daily. 

Breakfast  (7  to  8  o'clock). — Oatmeal, 
hominy,  cracked  wheat  (each  cooked  three 
hours  the  day  before  they  are  used),  served 
with  milk  and  sugar  or  butter  and  sugar. 
A  soft-boiled  egg,  a  lamb  chop,  hashed 
chicken.  Stale  bread  and  butter.  Bran 
biscuit  and  butter.  A  drink  of  milk. 

At  ten  o'clock  the  juice  of  one  orange  may 
be  given. 

Dinner  (12  o'clock). — Strained  soups,  and 
broths,  rare  beefsteak,  rare  roast  beef,  poul- 
try, fish.  Baked  potato,  peas,  string  beans, 
mashed  cauliflower,  mashed  peas,  strained 
stewed  tomatoes,  stewed  carrots,  spinach, 
asparagus  tips.  Bread  and  butter.  A  glass 
of  milk.  For  dessert:  plain  rice  pudding, 
plain  bread  pudding,  stewed  prunes,  baked 
or  stewed  apple,  junket,  custard,  or  corn- 
starch. 

Supper  (5.30  to  6  o'clock). — Farina,  cream 
of  wheat,  wheatena  (each  cooked  two  hours). 
Give  from  one  to  three  tablespoonfuls  served 
with  milk  and  sugar  or  butter  and  sugar  or 
butter  and  salt.  Drink  of  milk.  Zwieback 


Feeding  after  the  First  Year     81 

or  stale  bread  and  butter.  Twice  a  week, 
custard  or  cornstarch  or  junket  may  be  given 
or  a  tablespoonful  of  plain  vanilla  ice-cream. 
As  a  rule,  three  meals  answer  best  at  this 
period.  With  three  meals  a  child  has  better 
appetite  and  much  better  digestion,  and 
consequently  thrives  far  better  than  one 
whose  stomach  is  kept  constantly  at  work. 
Some  children,  however,  will  require  a  lunch- 
eon at  3  or  3.30  P.M.,  and  will  not  do  well 
without  it.  This  is  apt  to  be  the  case  with 
delicate  children,  particularly  those  under 
two  and  one-half  years  of  age.  If  food  is 
necessary  at  this  hour,  a  glass  of  milk  and  a 
graham  biscuit,  or  a  cup  of  broth  and  zwie- 
back will  answer  every  purpose.  Instead  of 
the  afternoon  meal,  the  child  may  relish  a 
scraped  raw  apple  or  a  pear.  The  fruit  at 
this  time  is  particularly  to  be  advised  if  there 
is  constipation.  Children  recovering  from 
serious  illness  will  require  more  frequent 
feeding. 

From  the  third  to  the  sixth  year. 

Breakfast. — Cracked      wheat,       cornmeal, 
hominy,   oatmeal   (each  cooked  three  hours 

6 


82      Feeding  after  the  First  Year 

the  day  before  they  are  used).  These  may 
be  served  with  milk  and  sugar  or  butter  and 
sugar  or  butter  and  salt.  A  soft-boiled  egg, 
omelet,  scrambled  egg,  chop.  Bread  and 
butter,  bran  biscuit  and  butter.  A  glass  of 
milk. 

Dinner. — Plain  soups,  rare  roast  beef, 
beefsteak,  poultry,  fish.  Potatoes  stewed  with 
milk  or  baked.  Peas,  string  beans,  strained 
stewed  tomatoes,  stewed  carrots,  squash, 
boiled  onions,  mashed  cauliflower,  spinach, 
asparagus  tips;  bread  and  butter.  For 
dessert:  Rice  pudding,  plain  bread  pudding, 
custard,  tapioca  pudding,  stewed  prunes, 
stewed  apples,  baked  apples,  raw  apples, 
pears  and  cherries. 

Supper. — Farina,  cream  of  wheat,  wheat  - 
ena  (each  cooked  two  hours).  Give  from 
two  to  three  tablespoonfuls  served  with  milk 
and  sugar  or  butter  and  sugar  or  salt  and 
butter.  Zwieback  or  stale  bread  and  butter. 
Bread  and  milk.  Milk  toast.  Scrambled 
egg  twice  a  week.  Custard  or  cornstarch 
each  once  a  w^eek ;  ice-cream  once  a  week ; 
bread  and  butter.  A  glass  of  milk. 

When  the  child  has  eggs  for  breakfast, 
they  should  not  be  repeated  in  any  form  for 


Diet  after  the  Sixth  Year       83 

supper.  Red  meat  should  be  given  but  once 
a  day.  When  the  child  has  a  chop  for  break- 
fast, he  should  have  poultry  or  fish  for  dinner. 
At  this  age  of  great  activity  and  rapid  growth, 
the  child  will  often  demand  food  between 
dinner  and  supper.  Carefully  selected  fruit, 
such  as  an  apple,  a  pear,  or  a  peach,  may  be 
given  at  this  time,  supplemented  by  a  gra- 
ham cracker  or  two,  or  by  stale  bread  and 
butter,  if  it  is  found  that  their  use  does  not 
interfere  with  the  evening  meal. 

DIET  AFTER  THE  SIXTH  YEAR 

When  the  normal  child  has  passed  the 
sixth  year  the  diet  may  be  considerably  ex- 
panded, approximating  to  that  of  the  adult 
in  variety:  certain  restrictions,  however,  are 
to  be  borne  in  mind.  Fried  foods  should  not 
be  given;  highly  seasoned  dishes,  such  as  pie, 
rich  puddings,  gravies,  and  sauces,  are  to  be 
avoided.  Salads  with  plain  dressing  may 
now  be  given.  Wine  and  beer,  coffee  and 
tea,  should  never  be  given  to  children  as  a 
beverage.  A  point  to  be  kept  in  mind  in 
feeding  children  at  this  age,  as  well  as  those 
who  are  younger,  is  the  proper  cooking  of 


84    How  the  Child  Should  be  Fed 

vegetables.  Everything  in  the  line  of  green 
vegetables  should  be  cooked  until  it  can 
readily  be  mashed  with  a  fork. 

HOW  THE  CHILD  SHOULD  BE  FED 

In  the  foregoing  articles  on  feeding  the 
author  has  endeavored  to  suggest  the  na- 
ture of  the  food  required  by  the  growing 
child,  and  the  intervals  at  which  food  should 
be  given.  This,  however,  does  not  entirely 
cover  the  subject.  A  child  should  never 
dine  with  adults  until  he  can  have  adult  diet, 
if  the  circumstances  of  the  family  will  permit 
him  to  dine  alone  or  with  other  children.  It 
is  a  species  of  cruelty  to  expect  a  hungry 
child  of  tender  age  to  sit  at  the  table,  see  and 
smell  the  fragrant  dishes,  and  be  forced  to 
content  himself  without  complaint  with  his 
restricted  fare.  The  author  recalls  this  cus- 
tom as  a  cause  of  many  tears,  disputes,  and 
fistic  encounters  with  attendants,  which 
formed  no  small  part  of  the  daily  routine  of 
his  early  life. 

In  feeding,  the  spoon  or  fork  must  come 
in  contact  only  with  the  food  and  the  child's 
mouth;  when  not  in  use  it  should  be  allowed 


How  the  Child  Should  be  Fed  85 

to  rest  on  the  clean  table-cloth.  If  it  falls  to 
the  floor  by  accident  it  should  be  dipped  in 
boiling  water  before  using  it.  Under  no 
circumstances  should  a  feeding  utensil  be 
allowed  to  come  in  contact  with  the  lips  of 
the  nurse  or  mother;  time  and  again  I  have 
seen  mothers  and  nurses  sip  or  swallow  the 
first  teaspoonful  of  the  food  which  is  to  be 
given,  to  determine  if  it  is  of  the  proper  tem- 
perature. At  other  times,  when  the  food  is 
not  particularly  attractive  to  the  child,  they 
will  place  the  spoon  in  their  mouths  as  though 
they  intended  to  take  it  themselves.  Others 
will  remove  from  the  spoon  with  their  own 
lips  adhering  particles  of  food. 

There  are  few  more  reprehensible  prac- 
tices than  the  foregoing,  and  if  parents  knew 
the  dangers  to  which  their  children  are  thus 
subjected  they  would  not  for  one  instant 
tolerate  them.  Any  one  of  the  many  forms 
of  pathogenic  bacteria  may  be  most  readily 
transferred  to  the  mouth  of  the  child  in  this 
way.  It  is  unquestionably  a  means  of  infec- 
tion with  tuberculosis,  diphtheria,  and  syph- 
ilis. The  germs  of  tuberculosis  and  diph- 
theria are  frequently  found  in  the  mouths 
of  perfectly  healthy  adults.  They  cause  no 


86  Condensed  Milk 

symptoms  of  disease  because  of  the  normal 
power  of  resistance  of  such  adults.  The 
resisting  powers  of  the  child,  however,  to 
these  micro-organisms  are  very  slight,  and 
when  they  are  carried  to  the  delicate  mucous 
membrane  of  the  infant's  mouth  and  throat 
they  thrive  actively,  the  child  develops 
diphtheria  or  tuberculosis,  and  the  family 
grieve  and  wonder  how  the  child  could  ever 
have  contracted  the  disease. 

CONDENSED  MILK 

Condensed  milk  should  never  be  selected 
as  a  food  for  a  baby  if  the  mother  can  afford 
to  buy  cows'  milk  and  can  learn  how  to  pre- 
pare and  care  for  it.  The  child's  natural 
food  is  the  mother's  milk ;  this  is  what  he  has 
a  right  to  demand.  If  mothers'  milk  can- 
not be  furnished  we  must  give  a  substi- 
tute which  will  provide  the  baby  with  the 
nourishment  contained  in  mothers'  milk. 
Analyses  by  many  chemists  of  thousands  of 
samples  of  good  mothers'  milk  show  that  it 
contains  approximately  3.5%  to  4%  of  fat, 
1.5%  of  proteid,  and  7%  of  sugar.  Con- 
densed milk,  diluted  one  to  twelve,  i.e.,  one 


Condensed  Milk  87 

part  condensed  milk  to  twelve  parts  of  water, 
— the  strength  taken  by  a  three-months-old 
child, — will  give  a  food  containing  .5%  of 
fat  and  .6%  of  proteid,  and  4%  of  sugar. 
Compare  these  figures  with  the  amount  of 
fat,  sugar,  and  proteid  contained  in  mothers' 
milk  and  it  will  readily  be  seen  that  the  baby 
is  not  getting  nearly  as  much  nourishment 
as  Nature  would  furnish  him.  If  the  mix- 
ture, using  the  condensed  milk,  is  made  in 
the  proportion  of  one  part  condensed  milk 
to  eight  parts  of  water — the  proper  strength 
for  a  six-months-old  child — there  will  still 
be  less  than  i%  of  fat,  and  a  lower  proteid 
than  in  mothers'  milk.  Condensed  milk  has 
its  uses,  however.  Many  mothers  cannot 
afford  to  buy  fresh  cows'  milk.  Some  have 
no  refrigerator  or  ice-box  in  which  to  keep  it. 
Condensed  milk,  on  account  of  the  cane  sugar 
which  has  been  added  to  it,  will  remain  fresh 
for  two  or  three  days  after  it  has  been  opened. 
It  is  a  most  inexpensive  means  of  feeding  the 
baby.  Further,  its  preparation  is  exceed- 
ingly simple,  and  many  mothers  are  too 
ignorant  to  appreciate  the  importance  of 
the  careful  preparation  of  cows'  milk.  That 
magnificent  charity,  the  Straus  Milk  Labo- 


«8  Condensed  Milk 

ratory,  which  furnishes  properly  prepared 
milk  at  a  minimum  price,  is  available  for 
comparatively  few  of  the  city's  poor. 

Condensed  milk  is  for  many  an  absolute 
necessity;  but  though  children  manage  to 
live  on  it,  they  never  thrive  satisfactorily. 
They  all  show  evidence  of  some  degree  of 
rickets,  unless  fat  in  some  form,  e.g.,  cod- 
liver  oil  or  cream,  is  given  in  addition,  to 
supplement  the  food:  and  very  few  children 
can  take  cod-liver  oil  during  the  summer 
months.  There  is  another  class  of  children 
for  whom  condensed  milk  has  served  us  well 
at  various  times.  They  are  the  young,  deli- 
cate infants,  with  very  weak  digestive  powers. 
Their  mothers  cannot  nurse  them,  wet-nurses 
are  impossible,  and,  for  some  reason,  the 
smallest  amount  of  cows'  milk,  most  care- 
fully adapted,  cannot  be  tolerated;  a  single 
teaspoonful  of  milk  or  cream  in  two  ounces 
of  plain  water,  whey,  weak  milk-sugar  water, 
or  barley  water  produces  colic  and  diarrhoea. 
I  have  successfully  fed  several  of  these  infants 
on  a  mixture  consisting  of  one  part  of  con- 
densed milk  and  twelve  parts  of  water.  I 
prefer  the  unsweetened  variety.  For  some 
unexplained  reason  these  children  digest  the 


Condensed  Milk  89 

condensed  milk  without  any  inconvenience 
and  do  fairly  well  for  a  few  weeks,  when  the 
secretion  of  the  digestive  juices  will  be  better 
established  and  a  weak  adapted  cows'-milk 
mixture  will  be  borne.  Condensed  milk  is 
also  useful  in  travelling.  During  journeys 
by  land  and  sea,  condensed  milk  with  boiled 
water  will  furnish  satisfactory  food  for  a 
limited  time  at  a  minimum  amount  of 
trouble. 

The  following  formulas  may  be  found  of 
service  to  those  who  for  any  reason  are  forced 
to  use  a  temporary  substitute  for  adapted 
cows'  milk: 

First  month  of  life:  i  part  of  condensed  milk 
to  1 6  of  water. 

Second  month:  i  part  of  condensed  milk  to 
14  of  water. 

Third  month:  i  part  of  condensed  milk  to  12 
of  water. 

Fourth  to  sixth  month:  i  part  of  condensed 
milk  to  10  of  water. 

After  the  sixth  month:  i  part  of  condensed 
milk  to  from  8  to  10  of  water. 

These  are  all  maximum  strengths;  for 
many  cases  a  greater  dilution  will  be  required. 


QO         The  Proprietary  Foods 

If  a  child  is  fed  on  condensed  milk  for  a 
longer  time  than  a  week,  cream  or  cod-liver 
oil  should  be  given, — each  feeding  being 
supplemented  by  from  one-half  to  two  tea- 
spoonfuls  of  cream,  or  from  ten  to  twenty 
drops  of  pure  cod-liver  oil. 

THE  PROPRIETARY  FOODS 

The  foods  on  the  market  prepared  for 
purposes  of  infant  feeding  are  almost  with- 
out number.  From  our  knowledge  of  the 
composition  of  mothers'  milk  we  learn  what 
nutritional  elements  and  approximately  in 
what  relative  proportions  these  elements 
must  exist  in  order  to  supply  the  child  with 
the  food  which  Nature  intended  him  to  have. 
The  examination  of  the  milk  of  thousands 
of  nursing  women  shows  that  it  ranges  from 
2.5  to  4  per  cent,  fat,  6  to  7  per  cent,  sugar, 
and  i  to  1.5  per  cent,  proteid.  These  figures 
may  be  put  down  as  the  normal  limits  of 
human  milk,  and  they  are  so,  simply  because 
the  infant  will  thrive  and  grow  when  the 
nutritional  elements  in  approximately  the 
above  proportions  are  supplied  to  him.  It 
is  within  these  limits  that  the  food  must  be 
kept  in  order  that  there  may  be  normal 


The  Proprietary  Foods          91 

growth  and  development;  though  of  course, 
wide  variations  from  these  may  be  of  tem- 
porary occurrence.  While  the  child  may 
exist  and  temporarily  do  fairly  well  on  a 
percentage  of  fat  lower  than  2.5,  he  will  in- 
variably show  defective  growth  if  the  proteid 
remains  persistently  under  i  per  cent.  The 
chief  disadvantage  in  the  infant  foods  which 
are  used  without  the  addition  of  cows'  milk, 
lies  in  the  fact  that  they  do  not  contain  the 
nutritional  elements  as  they  exist  in  normal 
breast -milk,  and  besides,  of  necessity,  they 
are  all  cooked  foods. 

In  selecting  a  substitute  for  mothers'  milk 
(page  54)  one  point  is  to  be  kept  in  mind, 
viz.,  the  substitute  should  contain,  in  a 
readily  assimilable  form,  the  nutritional 
elements  in  approximately  the  proportions 
and  forms  in  which  they  exist  in  mothers' 
milk.  All  other  feeding  is  defective.  It  is 
not  well  to  put  too  much  reliance  on  the 
analysis  sometimes  published  by  the  pro- 
prietary food  manufacturer.  This  type  of 
food  is  decidedly  weak  in  animal  fat,  for  the 
reason  that  there  is  no  means  of  keep- 
ing more  than  a  small  percentage  of  it  in  a 
food  without  its  becoming  rancid.  When 


92         The  Proprietary  Foods 

considerable  percentages  are  indicated  in  the 
analysis  it  is  certain  that  it  does  not  consist 
of  butter  fat.  The  quantity  of  animal  milk 
proteid  is  likewise  deficient,  and  what  is 
present  has  been  cooked,  thus  detracting 
materially  from  its  value  in  infant  nutrition. 
Scurvy  is  not  an  infrequent  result  of  the 
exclusive  use  of  these  foods. 

The  uses  of  proprietary  dried-milk  foods. — 
It  is  to  be  remembered  that  this  type  of  food 
is  condemned  because  of  its  being  an  unsuit- 
able food  when  used  exclusively  and  per- 
sistently. In  constipation  in  "runabout" 
and  older  children  \vho  are  on  a  general  diet, 
the  importance  of  milk  in  the  nutrition  is  a 
secondary  one,  and  is  often  an  important 
factor  in  the  production  of  constipation.  In 
these  cases  cows'  milk  may  be  replaced  by 
one  of  the  proprietary  dried-milk  foods  which 
has  a  laxative  effect,  with  a  good  deal  of 
advantage.  I  sometimes  employ  them 
further  in  other  disordered  states.  During 
acute  illness  and  in  convalescence  from  ill- 
ness and  in  certain  forms  of  malnutrition 
they  are  usually  readily  digested  and  may 
help  us  over  difficult  places. 

Proprietary  foods  to  n'JiicJi  fresh  ernes'  milk 


The  Proprietary  Foods         93 

is  added. — These  are  not  foods  in  the  usual 
acceptation  of  the  term,  and  if  they  are  used 
alone  independent  of  milk  the  patient  will 
soon  present  a  sorry  spectacle.  They  are 
sugars  largely,  being  composed  of  maltose 
and  dextrin,  which  are  derived  from  starch. 
Some  contain  a  considerable  quantity  of 
unconverted  starch.  When  added  to  the 
water  and  milk  mixtures  they  furnish  the 
soluble  carbohydrates  in  the  form  of  maltose 
and  free  starch,  and  thus  fulfil  this  function 
in  the  food  with  as  good  results  as,  but  usually 
no  better  than,  would  milk-sugar  and  a  ce- 
real gruel.  Maltose  is  a  laxative  sugar.  In 
case  of  constipation  in  the  bottle-fed  it  may 
replace  the  milk-sugar  in  equal  quantity, 
and  as  such  may  be  used  with  decided 
advantage  in  some  cases.  In  other  cases, 
this  change  to  maltose  is  without  effect. 
The  claim  that  when  added  to  cows'  milk 
these  proprietary  foods  increase  the  liability 
to  scurvy  is  without  foundation.  If  the  milk 
is  given  uncooked,  the  child  will  not  have 
scurvy,  regardless  of  the  nature  of  the  sugar; 
if  the  milk  is  heated  to  160°  or  170°  P.,  the 
child  may  have  scurvy  regardless  of  the  sugar. 
The  exploiting  of  photographs  of  crowing, 


94          The  Proprietary  Foods 

fat,  red-cheeked  babies  which  are  used  to 
illustrate  the  supposed  virtues  of  this  or  that 
manufacturer's  food  composed  principally 
of  maltose  is  not  a  very  high-minded  pro- 
cedure on  the  part  of  the  manufacturer  who 
thus  stoops  to  steal  the  credit  which  belongs 
to  a  cow!  According  to  my  observation, 
the  statement  that  the  addition  of  maltose 
to  cows'  milk  facilitates  its  digestion  is  un- 
founded. I  have  tried  it  in  many  cases,  but 
have  never  been  able  in  consequence  to  use 
a  stronger  cows'-milk  mixture,  a  higher 
proteid.  The  true  test  of  such  a  measure 
is  its  use  in  the  delicate  and  in  difficult  feed- 
ing cases,  and  not  in  well  babies  who  thrive 
regardless  of  the  sugar  employed.  The  mal- 
tose preparations,  then,  in  the  sense  that 
they  may  contain  a  small  amount  of  proteid 
and  a  laxative  sugar,  are  useful  and  to  be 
recommended  when  such  a  carbohydrate  is 
needed. 

The  proprietary  beef  foods. — Numerous  pre- 
parations of  this  nature  are  on  the  market 
and  there  has  been  abundant  opportunity 
to  test  their  value.  Without  going  into  a 
lengthy  discussion  as  to  how  and  under  what 
conditions  these  preparations  have  been  used, 


Pcptonized  Milk  95 

it  is  sufficient  to  say  that  as  a  means  of  nutri- 
tion in  children  they  play  a  very  unimportant 
part.  Their  principal  use  is  in  illness,  in 
which  they  act  as  a  stimulant,  and  to  a  less 
degree  as  a  food.  They  all  make  weak  pro- 
teid  mixtures  when  diluted  so  that  the  child 
can  take  them.  The  possibility  of  supplying 
any  great  amount  of  nutrition  to  the  economy 
by  their  use  is  small;  occasionally,  however, 
they  may  be  used  to  advantage.  When  milk 
is  withdrawn  they  may  be  added  to  the  cereal 
gruel  substitute.  If  there  is  diarrhoea,  great 
care  must  be  exercised,  as  the  proprietary 
beef  preparations  as  well  as  beef-juice  may 
increase  it.  On  account  of  the  creatinin 
which  they  contain,  they  should  not  be  given 
in  any  of  the  forms  of  nephritis.  Another 
feature  which  limits  their  use  is  that  a  child 
soon  tires  of  them.  They  can  rarely  be  given 
more  than  two  or  three  times  in  twenty-four 
hours.  Valentine's  is  the  preparation  I 
usually  select.  It  may  be  given  in  solution — 
one-quarter  to  one-half  teaspoonful  to  six 
ounces  of  the  diluent. 

J'EPTOXIZED  MILK 
Milk  is  peptoniml,  or  predigcsted,  for  the 


96  Peptonizcd  Milk 

purpose  of  partially  or  completely  digesting 
the  proteid,  the  curd,  before  it  is  given  to  the 
patient.  As  a  means  of  assistance  in  making 
a  milk  food  assimilable  its  field  of  usefulness 
is  limited.  So-called  complete  peptonization. 
produces  a  product  with  a  decidedly  bitter 
taste,  and  but  few  children  will  take  it.  Pep- 
tonized  milk,  however,  has  other  uses  than 
as  a  means  of  daily  feeding.  Peptonized 
milk  in  which  there  is  a  complete  conversion 
of  the  casein  has  been  most  useful  in  two 
types  of  cases.  During  acute  or  chronic 
illness  when  a  child  cannot  take  food  by  the 
natural  method,  as  in  diphtheritic  paralysis, 
or  when  he  will  not  swallow  on  account  of  an 
acute  inflammatory  disease  of  the  throat 
such  as  peritonsillitis,  retropharyngeal  ab- 
scess, or  retropharyngeal  adenitis,  or  when 
he  is  in  a  comatose  condition  from  any  cause 
except  intestinal  infection,  the  feeding  of 
completely  peptonized  milk  by  gavage,  intro- 
ducing it  into  the  stomach  through  a  tube, 
is  of  inestimable  value.  In  such  conditions, 
as  a  valuable  aid  in  nutrition,  frequent  refer- 
ence is  made  to  it  throughout  this  book.  In 
conditions  when  stomach -feed  ing  is  impos- 
sible either  by  gavage  or  the  natural  method 


Peptonized  Milk  97 

— conditions  met  with  in  persistent  vomiting 
due  to  acute  cerebral  diseases,  in  recurrent 
vomiting,  in  acute  gastric  indigestion — and 
as  an  accessory-  means  of  feeding  when  suffi- 
cient nourishment  cannot  be  taken  by  the 
stomach,  the  colon-feeding  of  completely 
peptonized  skimmed  milk  has  a  decided  field 
of  usefulness,  and  in  this  way  I  often  employ 
it.  Feeding  by  means  of  the  bowel,  how- 
ever, is  usually  possible  in  children  for  a  few 
days  only,  because  of  the  local  irritation 
produced  by  the  nutriment  and  by  the  pas- 
sage of  the  tube.  Skimmed  peptonized  milk 
with  the  addition  of  the  white  of  egg  makes 
the  best  nutrient  enema  that  I  have  used. 
It  should  be  given  at  a  temperature  be- 
tween 90°  and  95°  F.  at  from  six-  to 
eight-hour  intervals.  The  tube  should  be 
introduced  at  least  nine  inches.  In  cases  of 
recurrent  vomiting  I  have  repeatedly  seen 
both  hunger  and  thirst  relieved  by  feeding 
in  this  way.  The  following  are  the  different 
methods  for  the  peptonization  of  milk. 

Immediate  process. — Fifteen  minutes  before 
feeding  add  from  one-eighth  to  one-quarter 
of  the  contents  of  a  Fairchild  peptonizing 
tube  to  the  milk  mixture  which  is  in  the 


98  Peptonizcd  Milk 

nursing-bottle  ready  for  use.  Place  the 
bottle  in  water  at  a  temperature  of  from 
1 10°  to  120°  P.,  and  let  it  remain  until  fifteen 
minutes  have  elapsed.  The  amount  of  the 
powder  used  and  the  degree  of  heat  of  the 
water  depend,  of  course,  upon  the  amount  of 
milk  in  the  nursing-bottle. 

Cold  process. — Put  four  ounces  of  cold 
water  into  a  clean  quart  bottle  and  dissolve 
in  it,  by  shaking  thoroughly,  the  powder 
contained  in  one  of  the  Fairchild  peptonizing 
tubes;  add  a  pint  of  cold  fresh  milk,  shake 
the  bottle  again,  and  immediately  place  it 
upon  ice — directly  in  contact  with  it. 

Partially  pcptonizcd  milk. — Put  four  ounces 
of  cold  water  and  the  powder  contained  in 
one  of  the  Fairchild  peptonizing  tubes  into  a 
clean  saucepan,  and  stir  well;  add  a  pint  of 
cold  fresh  milk  and  heat  with  constant  stir- 
ring to  the  boiling-point.  The  heat  should 
be  so  applied  that  the  milk  will  come  to  a 
boil  in  ten  minutes.  Let  it  cool  until  luke- 
warm, then  strain  into  a  clean  bottle  or 
glass  jar,  cork  tightly,  and  keep  in  a  cold 
place.  The  bottle  or  jar  should  always  be 
well  shaken  before  and  after  pouring  out  a 
portion. 


Milk  for  Travelling  99 

Partially  peptonized  milk,  if  properly  pre- 
pared, will  not  become  bitter. 

Completely  peptonized  milk. — Put  four 
ounces  of  cold  water  and  the  powder  con- 
tained in  one  of  the  Fairchild  peptonizing 
tubes  into  a  clean  quart  bottle  and  shake 
thoroughly;  add  a  pint  of  cold  fresh  milk 
and  shake  again;  then  place  the  bottle  in  a 
pail  or  kettle  of  warm  water — about  115°  P., 
or  not  too  hot  to  immerse  the  hand  in  it  with- 
out discomfort.  Keep  the  bottle  in  the 
water-bath  for  thirty  minutes.  Put  it  im- 
mediately upon  ice — directly  in  contact 
with  it. 

MILK  FOR  TRAVELLING 

In  making  long  journeys  with  infants  by 
land  or  water,  the  feeding  of  the  child  is  an 
important  matter,  and  advice  is  often  sought 
by  mothers  who  wish  to  make  the  contem- 
plated trip  with  the  least  possible  risk.  It 
is,  of  course,  desirable  that  no  change  be 
made  in  the  milk  commonly  used,  and  there 
are  means  of  treating  the  milk  and  of  keeping 
it  which  enable  us  to  assure  the  patient  of 
reasonable  safety.  It  is  mv  custom  with 


ioo  Milk  for  Travelling 

city  children  to  have  the  milk  prepared  at 
the  Walker-Gordon  Laboratory,  where  at  a 
trifling  expense  small  ice-boxes  can  be  ob- 
tained which  contain  sufficient  space  for  a 
few  days'  supply  of  milk  and  which  can  be 
conveniently  carried  on  cars  and  boats.  They 
have  also  larger  boxes  with  a  capacity  of 
twelve  quarts,  which  may  be  used  for  an 
ocean  voyage.  The  smaller  box  will  need 
refilling  with  ice  once  or  twice  a  day,  which 
is  usually  readily  secured.  The  larger  box, 
for  ocean  voyages,  is  packed  in  ice  and  placed 
in  a  cold-storage  room  of  the  vessel  and  will 
not  need  repacking  during  the  trip.  Labo- 
ratory milk,  however,  is  available  for  com- 
paratively few. 

Milk  prepared  at  home  for  a  journey  should 
be  cooled  to  45°  F.  as  soon  as  it  is  drawn,  and 
kept  at  this  temperature  until  it  can  be  ster- 
ilized at  a  temperature  of  212°  F.  for  twenty 
minutes.  It  then  should  be  cooled  rapidly 
to  at  least  50°  F.  and  kept  at  this  point  until 
used.  These  directions  can  be  carried  out 
by  any  intelligent  family.  When  this  is  done 
the  milk  will  be  safe  for  use  for  the  time  re- 
quired— from  seven  to  eight  days.  Even 
the  suggestion  as  to  the  making  of  an  ice-box 


Diet  during  Illness  101 

can  be  followed  in  any  town  or  village.  All 
that  is  required  is  the  ice-box,  one-quart 
fruit  jars  or  one-quart  milk  bottles,  and  clean 
milk.  Those  who  for  any  reason  cannot 
avail  themselves  of  the  milk  thus  preserved 
will  find  in  canned  condensed  milk  a  fairly 
good  substitute.  If  kept  on  ice  and  wrapped 
in  a  clean  towel,  a  can  of  condensed  milk  may 
safely  be  used  for  three  days  after  opening. 
Formulas  suited  for  the  various  months  of 
infancy  will  be  found  in  the  section  on  Con- 
densed Milk  (page  89). 

DIET  DURING  ILLNESS 

The  digestive  capacity  of  every  child  is 
diminished  during  illness,  depending  largely 
upon  the  age  of  the  child  and  the  severity 
of  the  disease.  The  younger  the  child,  the 
greater  the  incapacity.  This  is  fairly  con- 
stant with  all  the  ailments  of  childhood, 
including,  of  course,  those  which  directly 
affect  the  gastro-enteric  tract.  In  a  mod- 
erately severe  bronchitis,  with  a  degree  or 
two  of  fever,  the  digestive  capacity  is  slightly 
diminished  and  a  25  per  cent,  reduction  in 
tin1  strength  of  the  food  will  answer.  Duriiii/ 


102  Diet  during  Illness 

the  critical  stage  of  a  lobar  pneumonia  the 
digestive  powers  are  held  in  abeyance  and 
predigested  foods  and  alcohol  must  sustain 
the  patient.  During  an  attack  of  measles, 
scarlet  fever,  broncho-pneumonia,  or  diph- 
theria in  bottle-fed  infants,  at  the  height  of 
the  disease,  it  is  my  custom  to  reduce  the 
strength  of  the  food  one-half  by  the  addition 
of  water,  to  make  up  for  the  quantity  re- 
moved. For  ailments  of  lesser  severity, 
such  as  bronchitis,  with  a  temperature  of 
1 00°  to  101°  F.,  or  chicken-pox,  or  mild 
measles,  I  reduce  the  strength  of  the  food 
from  one-fourth  to  one-third.  In  any  mild 
ailment  or  injury  which  confines  a  child  to 
its  bed,  the  food  strength  should  be  cut  down, 
for  inactivity  as  well  as  disease  lessens  the 
digestive  capacity. 

Among  nurslings  and  the  bottle-fed  these 
precautions  are  particularly  necessary.  A 
child  with  fever  is  apt  to  be  thirsty  and  to 
take  more  food  than  in  health.  This  is  fre- 
quently the  case  in  summer  diarrruea.  In 
order  to  avoid  this  taking  of  too  much  food, 
I  not  only  order  the  milk  to  be  diluted  for 
the  bottle-fed,  but  I  instruct  the  mothers  of 
nurslings  to  give  a  drink  of  water  immediately 


Diet  during  Illness  103 

before  each  nursing  and  between  nursings, 
and  then  to  allow  the  child  to  nurse  only  one- 
half  or  two-thirds  the  usual  time.  For  the 
bottle-fed,  one-half  to  two-thirds  of  the 
contents  of  each  bottle  is  removed  and  the 
quantity  replaced  by  boiled  water,  so  that 
the  amount  of  fluid  given  remains  the 
same. 

If  the  child  is  a  "runabout,"  over  two 
years  of  age,  he  is  given  broths  and  thin  gruel 
— one-half  milk  and  one-half  gruel.  By 
carefully  watching  the  stools,  thus  fitting 
the  food  to  the  child's  capacity,  we  will  avoid 
grave  intestinal  complications  which,  during 
the  summer,  often  prove  to  be  more  serious 
than  the  original  ailment.  In  the  acute 
gastro-enteric  troubles,  and  in  typhoid  fever, 
all  milk  must  be  discontinued. 

The  art  of  feeding  in  illness.' — Not  only  is 
food  oftentimes  taken  in  insufficient  quantity 
in  illness,  but  in  many  cases  it  is  absolutely 
refused.  In  other  cases,  during  coma  and 
asthenic  states,  swallowing  is  impossible. 
In  delirium  and  in  conditions  of  collapse 
nourishment  must  be  given,  and  when  this 
is  impossible  by  the  natural  method,  we 
have,  as  temporary  substitutes,  gavagc,  oil 


104  Diet  during  Illness 

inunctions,  and  rectal  feeding — all  referred 
to  elsewhere. 

Forcing  the  child  to  take  nourishment  by 
the  mouth  is  rarely  necessary.  Coaxing  and 
bribing  ordinarily  succeed  far  better.  For  a 
child  from  three  to  five  years  of  age  a  bright 
new  penny  possesses  much  persuasive  power. 
The  child  will  usually  take  its  food  better 
from  those  to  whom  it  is  accustomed,  like 
the  mother  or  nursery  maid.  The  trained 
nurse  should  understand  that  while  un- 
acquainted with  the  patient,  the  simpler 
requirements  of  the  child  are  to  be  looked 
after  by  others  to  whom  the  patient  is  accus- 
tomed. The  nourishment  should  be  as  pal- 
atable as  possible  and  served  in  bowls,  cups, 
or  plates  that  are  attractive  to  the  patient 
because  of  color,  pictures,  or  peculiarities  of 
shape.  Junket,  flavored  with  vanilla,  served 
cold  is  a  favorite  food  for  sick  children  of  the 
"runabout"  age.  Frozen  custard,  and 
home-made  ice-cream,  made  with  one-third 
cream  and  two-thirds  milk,  will  usually  be 
well  taken.  Toast,  dry  bread,  and  crackers 
made  in  peculiar  shapes  are  attractive  to  the 
child.  In  not  a  few  cases  1  have  succeeded 
in  feeding  satisfactorily  children  two  or  three 


Vomiting  105 

years  old,  when  several  other  schemes  had 
failed,  by  allowing  the  temporary  return  to 
the  bottle,  from  which  they  had  been  weaned 
for  a  year  or  so. 

In  these  difficult  feeding  cases  the  child's 
peculiarities  and  wishes  must  be  studied. 
Children  in  illness  require  water.  Often- 
times they  will  take  it  in  insufficient  quan- 
tities. Those  who  refuse  plain  water  will 
often  take  ginger  ale,  sarsaparilla,  or  vichy. 
In  the  event  of  these  drinks  being  well  taken, 
they  may  be  given  freely.  In  the  acute  in- 
fectious diseases,  which  include  pneumonia, 
free  water-drinking  is  a  therapeutic  measure 
of  no  mean  value. 

VOMITING 

A  sudden  attack  of  vomiting  may  usher 
in  any  serious  illness,  with  fever.  Thus,  it 
may  be  the  initial  symptom  of  pneumonia, 
scarlet  fever,  or  meningitis.  By  far  the  most 
usual  cause,  however,  will  be  found  inti- 
mately connected  with  the  stomach,  usually 
an  acute  attack  of  indigestion.  Bottle-fed 
children  furnish  the  greatest  number  of  pa- 
tients, as  these  children  are  almost  ahvavs 


io6  Habitual  Vomiting 

overfed,  and  more  or  less  badly  fed.  With 
the  onset  of  a  sharp  attack  of  vomiting, 
particularly  if  it  occurs  during  hot  weather, 
the  milk  diet  should  immediately  be  discon- 
tinued. Small  quantities  of  boiled  water, 
one-half  to  two  ounces  of  barley  water,  or 
rice  water,  or  plain  broths  may  be  given  every 
hour  or  two.  In  the  obstinate  cases,  quite 
a  period  of  rest  should  be  given  the  stomach. 
From  twenty-four  to  thirty-six  hours  will 
often  be  necessary  before  the  child  will  be 
able  to  retain  even,  a  teaspoonful  of  water. 
No  milk  should  be  given  until  the  vomiting 
has  ceased  for  at  least  two  days.  When  the 
milk  is  resumed  it  should  be  diluted  five  or 
six  times  with  water  and  at  first  only  a  small 
quantity  of  the  mixture  given.  In  many 
of  these  cases  a  stomach  washing  will  speedily 
correct  the  trouble.  If  the  stomach  bears 
the  food  well  its  strength  may  gradually  be 
increased  by  an  additional  half-ounce  or 
ounce  of  milk  to  each  feeding  daily,  until  the 
former  diet  is  resumed. 

HABITUAL  VOMITING 
Many  children  regurgitate  or  vomit  a  por- 


Malnutrition  and  Marasmus    107 

tion  of  every  feeding.  This  means  one  thing 
always  —the  child  has  been  or  is  overfed. 
He  is  given  the  food  too  strong,  or  the  amount 
is  greater  than  his  capacity,  or  he  is  fed  at  too 
frequent  intervals.  In  either  case  the  stom- 
ach relieves  itself.  Many  of  these  children 
who  regurgitate  after  each  feeding  thrive 
finely  in  spite  of  the  loss.  Enough  is  retained 
for  their  nourishment,  and  they  gradually 
become  accustomed  to  the  strong  food  and 
no  serious  harm  results.  Such  a  stomach, 
however,  is  liable  to  behave  very  badly  dur- 
ing hot  weather.  During  any  illness,  in  fact, 
which  taxes  the  patient's  strength,  the  dis- 
ordered stomach  stands  ready  to  furnish  an 
unpleasant  complication. 

The  treatment  of  habitual  vomiting  in  the 
bottle-fed  is  by  a  suitable  adaptation  of 
the  food  and  stomach  washing.  Among  the 
breast-fed  the  breast-milk  will  have  to  be 
examined  and,  if  found  unsuitable,  corrected 
if  possible.  If  too  frequent  nursings  or  night 
nursings  have  been  allowed  they  should  be 
discontinued. 

MALNUTRITION  AND  MARASMUS 
Bv  malnutrition  we  understand  that  con- 


io8    Malnutrition  and  Marasmus 

dition  in  which  a  child  for  some  reason  fails 
to  gain  in  weight  or  loses  steadily  for  a  con- 
siderable period  of  time.  Cases  present  all 
degrees  of  severity,  from  those  in  which  there 
is  merely  a  temporary  loss  of  weight,  to  those 
of  an  extreme  degree  of  malnutrition,  which 
latter  condition  we  term  marasmus.  A  ma- 
rasmatic  infant  presents  one  of  the  most 
pitiful  pictures  we  are  called  to  look  upon: 
the  dry  skin  drawn  tightly  over  the  fleshless 
bones,  the  sunken  eye,  the  distended  abdo- 
men, the  anxious,  tired  expression,  and  the 
whining  cry  furnish  a  picture  of  starvation 
so  pathetic  that  only  those  hardened  by  long 
familiarity  with  such  cases  can  look  upon 
them  unmoved. 

When  the  history  of  such  infants  has  been 
looked  into  it  will  be  learned  that  errors  in 
feeding  contributed  largely  to  bringing  them 
to  their  woeful  condition.  Many  of  these 
children  came  into  the  world  strong  and  vig- 
orous, the  mothers  were  unable  to  nurse  them, 
and  the  food  selected  did  not  agree  with  them. 
Cows'  milk,  perhaps,  was  given,  unsuitably 
adapted, — it  usually  is  given  too  strong  to 
young  infants, — at  any  rate  it  disagreed,  and 
the  proprietary  meal  foods  were  brought  into 


Malnutrition  and  Marasmus    109 

use,  one  after  another,  as  they  were  suggested 
by  well-meaning  friends,  each  to  do  its  share 
of  damage  and  in  turn  to  be  discarded.  The 
stomach  bore  the  ill-usage  for  a  time,  but 
soon  became  so  disturbed  that  the  digestion 
of  rational  food  was  out  of  the  question. 
Many  of  these  children  finally  reach  the  point 
where  predigested  foods  fail  to  be  assimi- 
lated ;  such  cases,  of  course,  are  hopeless. 

It  is  a  source  of  amusement  oftentimes  to 
note  the  assurance  with  which  laymen  will 
advise  a  mother  that  such  and  such  a  food 
is  the  only  one  for  the  baby,  when  they  pos- 
sess neither  the  intelligence  nor  the  training 
necessary  to  judge  of  the  child's  digestive 
peculiarities  or  capacity ;  in  fact,  they  know 
no  more  of  the  child's  requirements  or  the 
chemical  composition  of  the  food  suggested, 
or  even  what  should  be  the  composition  of 
the  baby's  food,  than  does  the  unfortunate 
babe  itself. 

If  there  is  inherited  weakness,  or  a  low 
vitality  from  any  cause,  the  downward  course 
may  be  very  rapid.  There  are  two  or  three 
weeks  of  suffering,  and  then  the  end.  If  seen 
before  the  vital  powers  are  at  too  low  an  ebb, 
these  children,  by  very  careful  and  intelligent 


no   Malnutrition  and  Marasmus 

management,  can  be  saved.  They  should 
be  handled  only  when  necessary  for  dressing 
and  bathing.  The  nourishment  given  must 
at  first  be  very  weak,  and  its  effects  carefully 
watched  from  day  to  day,  the  strength  and 
amount  of  the  food  being  increased  or  de- 
creased, as  may  be  found  necessary.  A  brine 
bath  should  be  given  daily,- — a  tablespoonful 
of  salt  to  a  gallon  of  water.  The  tempera- 
ture of  the  water  should  be  100°  to  105°  P. 
The  child  should  remain  in  the  water  ten 
minutes,  being  rubbed  well  with  the  hand 
while  in  the  water.  When  removed,  it  should 
be  placed  in  a  large  bath  towel  and  dried 
quickly.  When  dry,  rub  one  tablespoonful 
of  unsalted  lard  or  goose-gre?se  into  the  skin. 
Flannel  should  1  >e  worn  next  to  the  skin  except 
during  very  warm  summer  weather. 

Marasmatic  children  when  sleeping  should 
not  be  allowed  to  remain  long  in  one  position  ; 
they  should  frequently  be  turned  from  the 
back  to  the  side,  and  from  one  side  to  the 
other.  A  hot-water  bottle  to  the  feet  will 
often  be  necessary  when  sleeping.  To  a  child 
suffering  from  malnutrition,  fresh  air  is  as 
indispensable  as  loud.  During  the  warm 
weather  if  he  can  be  protected  from  the  sun 


Summer  Diarrhoea  in 

the  child  should  be  kept  out  of  doors  from 
morning  until  night.  During  the  entire  year 
he  should  sleep  with  the  window  open.  Dur- 
ing the  winter  months  he  should  be  taken 
out  of  doors  for  at  least  one-half  hour  even' 
pleasant  day.  When,  on  account  of  the 
inclement  weather  or  excessive  cold,  he  can- 
not go  out,  he  should  be  dressed  as  for  the 
daily  outing,  taken  into  a  room  all  the  win- 
dows of  which  have  been  open  for  at  least 
one-half  hour ;  here,  placed  in  a  baby-carriage 
and  warmly  covered,  with  a  hot-water  bottle 
at  his  feet,  he  is  allowed  to  enjoy  the  fresh 
air  for  several  hours  each  day.  This  bright- 
ens the  eye,  brings  color  to  the  cheek,  and  an 
invigorated  baby  returns  to  the  nursery. 

SUMMER  DIARRHOEA 

Summer  diarrhoea  is  the  cause  of  more 
deaths  among  young  children  in  our  large 
cities  than  any  other  one  factor.  So  preva- 
lent and  so  dangerous  an  illness  should  be 
better  understood  by  the  laity  than  is  the 
case  at  the  present  time.  Every  illness  of 
this  nature  must  be  considered  as  a  case  of 
poisoning.  The  vomiting  and  diarrhu-a  are 


ii2  Summer  Diarrhoea 

conservative  efforts  on  the  part  of  Nature 
to  get  rid  of  the  offending  material.  The 
poisoning  may  result  from  direct  infection. 
It  may  be  due  to  bacteria-laden  milk,  unclean 
feeding  apparatus,  or  to  any  means  whereby 
poisonous  germs  find  entrance  into  the  gastro- 
intestinal tract. 

There  may  also  be  an  indirect  infection  or 
self-poisoning — an  auto-intoxication.  Heat 
plays  an  important  part  in  these  cases.  The 
child  is  greatly  depressed ;  the  digestive  pro- 
cesses are  not  properly  carried  on — the  milk 
taken  from  the  breast  or  bottle  is  not  acted 
upon  by  digestive  juices  of  the  usual  strength 
and  volume;  decomposition  takes  place; 
poisons  are  generated  and  absorbed,  produc- 
ing fever  and  prostration,  the  intestine  en- 
deavors to  empty  itself  of  the  offending 
material  and  diarrhoea  results. 

Cholera  infantum,  inflammation  of  the 
bowels,  dysentery' — all  very  bad  terms  but 
in  common  use — are  due  primarily  to  the 
causes  above  mentioned.  Such  being  the 
nature  of  summer  diarrhoea,  the  duties  of 
the  mother  in  such  eases  should  be  clearly 
understood.  The  intestine  must  be  relieved 
of  as  much  as  possible  of  the  material  which 


Summer  Diarrhoea  1 1 3 

is  causing  the  trouble.  For  this  purpose 
give  two  teaspoonfuls  of  castor-oil,  and  nour- 
ishment which  will  not  furnish  a  fertile  soil 
for  the  growth  of  bacteria.  For  this  reason 
milk  must  be  stopped  with  the  first  symptom 
of  the  trouble.  The  mother  will  never  make 
a  mistake  in  these  cases ;  in  fact,  many  a  life 
will  be  saved  by  an  immediate  dose  of  castor- 
oil  and  by  promptly  stopping  the  milk  diet 
before  the  physician  arrives.  Milk,  in  addi- 
tion to  furnishing  a  medium  for  the  growth 
of  bacteria,  forms  into  tough  curds  which 
must  pass  the  entire  length  of  the  intestinal 
tract,  exciting  a  very  active  peristalsis,  caus- 
ing pain  and  an  increase  in  the  number  of 
passages.  The  diet  substituted  for  milk 
should  consist  of  some  cereal  water,  plain  or 
dextrinized ;  either  barley,  wheat,  or  rice  may 
thus  be  used;  broths,  whey,  or  substances 
of  like  nature  may  be  given  alternately  or 
combined  with  the  cereal  waters.  Salt 
should  be  added  to  the  barley-water  if  it  is 
given  plain.  I  prefer  to  give  one  or  two 
ounces  of  chicken  or  mutton  broth  with  the 
barley-water.  A  teaspoon  ful  of  sherry  wine 
or  one  teaspoonful  of  liquid  peptonoids  may 
be  added  to  the  barlev-waler.  Broths  must 


ii4  Summer  Diarrhoea 

be  given  in  small  amounts,  as  not  infre- 
quently they  have  a  decidedly  laxative 
effect. 

It  is  not  advisable  to  give  one  food  con- 
tinuously, as  the  child  will  tire  of  it.  The 
addition  to  the  barley-water  of  one  of  the 
substances  suggested  will  so  change  its  taste 
that,  if  necessary,  the  diet  may  be  continued 
for  several  days.  The  quantity  should  cor- 
respond to  the  amount  of  food  taken  in  health , 
but  the  intervals  between  feedings  should 
be  shorter — every  two  hours  if  practicable. 
For  instructions  for  cooking  the  cereal  water, 
see  Formula,  pages  oo. 

A  patient  is  not  to  be  considered  out  of 
danger  nor  should  the  milk  diet  be  resumed 
until  the  stools  are  normal  and  not  over  two 
or  three  daily.  In  many  cases  milk  must 
be  excluded  for  two  or  three  weeks.  When 
it  is  resumed,  care  must  be  exercised  in  not 
giving  too  strong  a  mixture ;  many  a  relapse 
is  due  to  this  error.  The  first  day  not  over 
one-quarter  ounce  of  milk  should  be  given 
in  each  feeding  of  the  barley-water.  If  this 
causes  no  disturbance  one-half  ounce  may  be 
given  the  next  day,  increasing  from  one- 
quarter  to  one-half  ounce  daily,  if  there  is  no 


Summer  Diarrhoea  115 

return  of  the  diarrhoea,  until  the  customary 
strength  is  reached.  Many  children  will  not 
be  able  to  digest  nearly  as  strong  a  mixture 
as  they  were  taking  before  their  illness,  and 
the  diluted  milk  mixture  will  have  to  be  sup- 
plemented by  the  use  of  dextrinized  cereal 
gruels,  cereal  jellies,  scraped  beef,  the  white 
of  an  egg,  and  other  easily  digested  sub- 
stances. Every  year  I  have  patients  who, 
after  such  an  attack,  cannot  take  a  particle 
of  milk  without  harm  until  the  autumn  is 
well  advanced. 

Bowel  irrigation. — Washing  out  the  bowels 
once  or  twice  a  clay  is  also  very  helpful  in  the 
treatment  of  these  cases  if  the  stools  contain 
any  blood  or  much  mucus.  This  is  done  as 
follows:  A  No.  14  soft-rubber  English  cathe- 
ter, one  that  will  not  bend  upon  itself,  if 
properly  used,  is  attached  to  a  fountain 
syringe.  The  bag  should  be  held  three  feet 
above  the  patient,  who  should  lie  on  the  left 
side  with  the  legs  well  drawn  up.  The  tip  of 
the  well-oiled  catheter  is  passed  into  the 
rectum  a  distance  of  two  inches,  when  the 
water  is  allowed  to  pass  in  slowly.  The 
water  will  distend  the  parts  and  facilitate 
the  further  introduction  of  the  tube.  Press 


n6  Summer  Diarrhoea 

the  folds  of  the  buttocks  together  until  the 
colon  is  filled.  This,  in  a  child  eighteen 
months  of  age,  will  require  from  twenty -four 
to  thirty  ounces  of  water.  When  not  less 
than  one  pint  has  passed  in  allow  the  water 
to  pass  out  alongside  the  tube. 

Prevention. — A  word  regarding  the  pre- 
vention of  summer  diarrhoea.  It  is  not 
enough  that  the  child  be  given  properly 
prepared  pasteurized  or  sterilized  milk  or 
breast-milk, — he  must  be  made  comfortable 
during  the  hot  weather.  The  clothing  should 
be  of  the  lightest.  On  very  hot  days,  if  in 
the  country-,  he  should  be  kept  in  the  open 
air,  in  the  shade;  if  in  the  city,  the  coolest 
room  in  a  house  or  an  apartment  is  far  better 
than  the  dusty  streets.  Whether  in  the  city 
or  count ry,  on  very  hot  days  two  or  three 
fifteen-minute  spongings  with  water  at  60°  F. 
will  add  greatly  to  the  child's  comfort. 

Reduction  of  food. — Further,  we  know  that 
the  digestive  capacity  is  lessened  during  the 
heated  term,  and  the  milk  should  be  reduced 
in  strength  from  one-quarter  to  one-third, 
adding  boiled  water  to  take  the  place  of  the 
milk  removed. 

Cleanliness. — As  infection  mav  be  carried 


Baths  1 1 7 

to  the  feeding  utensils  by  the  hands  of  the 
nurse  or  mother,  she  should  always  wash 
them  most  carefully  with  soap  and  water 
before  handling  bottles  or  nipples,  or  pre- 
paring the  infant's  food.  Inasmuch  as  other 
children  may  become  infected,  or  reinfection 
take  place  in  the  one  already  ill,  a  child  with 
summer  diarrhoea  should  be  isolated. 

BATHS 

The  newly  born  child  should  be  given  daily 
a  basin-bath  with  lukewarm,  boiled  water  and 
castile  soap  until  the  cord  falls  and  the  navel 
heals.  When  this  has  taken  place  the  tub- 
bath  may  be  given.  The  temperature  of  the 
bath  for  the  very  young  infant  should  not  be 
below  95°  F.  nor  above  100°  F.  Very  young 
children  should  not  be  kept  in  the  water  more 
than  three  minutes.  After  the  third  or 
fourth  month  a  temperature  of  90°  or 
95°  F.  is  best,  the  child  being  kept  in  the 
water  about  five  minutes.  At  this  age  I 
prefer  to  have  the  tub-loath  given  at  night, 
just  before  the  child  is  put  to  bed.  A  basin - 
bath  may  be  given  in  the  morning.  When 
the  child  is  a  year  old  and  fairly  vigorous, 


n8  Baths 

the  temperature  of  the  water  at  the  begin- 
ning of  the  bath  should  be  90°  F.  This 
should  gradually  be  reduced  to  80°  F.  by 
the  addition  of  cold  water,  the  child  being 
vigorously  rubbed  with  the  hand  while  in 
the  water.  The  temperature  of  the  room 
should  be  from  76°  to  80°  F.  during  the  bath, 
and  windows  and  doors  should  be  closed. 
When  removed  from  the  tub  the  baby  should 
be  dried  quickly  and  thoroughly,  and  the 
folds  of  the  skin  should  be  well  powdered. 
A  sponge  should  never  be  used  in  any  portion 
of  the  bathing  process.  It  should  never  be 
included  in  the  nursery  outfit.  It  is  never 
clean  after  it  has  once  been  used.  Some 
children  have  a  dread  of  the  bath,  and  cry 
frantically  when  placed  in  the  water.  This 
is  due  to  fear,  and  may  usually  be  overcome 
by  placing  a  sheet  over  the  tub  and  lowering 
the  child  on  it  into  the  water. 

The  cold  douche. — For  "runabouts"  from 
two  to  three  years  old  it  may  not  be  wise  to 
use  water  below  70°  F.,  but  many  patients 
over  three  years  have  the  water  applied  in 
the  form  of  a  cold  douche  after  the  cleansing 
bath,  during  the  entire  twelve  months  at  the 
temperature  at  which  it  runs  from  the  faucet. 


Baths  119 

In  winter,  in  New  York  houses,  this  ranges 
from  50°  to  60°  F. 

In  giving  the  cold  douche  the  child  should 
stand  in  warm  water  covering  the  ankles. 
The  douche  may  be  used  in  the  form  of  a 
spray  or  shower  or  the  water  may  be  applied 
by  means  of  a  sponge  moistened  with  it  at 
the  desired  temperature.  The  head,  if  the 
shower  or  spray  is  used,  should  be  suitably 
protected  by  an  oil-skin  or  rubber  bathing 
cap. 

After  the  cold  douche  there  should  be  a 
vigorous  friction  of  the  skin  with  a  rough 
towel.  If  there  is  not  a  quick  reaction,  if  the 
skin  does  not  become  warm  and  glowing, 
warmer  water  should  be  used.  So  also  with 
blueness  of  the  extremities  and  "goose  flesh  "  ; 
use  water  less  cold,  but  do  not  discontinue 
the  douche. 

In  the  great  majority  of  homes  the  bathing 
of  the  children  can  be  carried  on  with  greater 
convenience  immediately  before  their  bed- 
time. The  child  should  receive  the  warm 
bath  and  the  cold  douche,  and  then,  in 
night-clothes,  a  warm  wrapper,  and  suitable 
foot  covering,  he  should  eat  his  supper.  How- 
ever, if  this  time  is  not  convenient,  he  may 


120  Baths 

be  given  the  evening  meal  at  5.30  or  6.30, 
followed  in  one  hour  by  the  bath  and  bed. 

Tub-baths  for  fever. — Place  the  child  in 
water  at  a  temperature  of  95°  F.  and  reduce 
to  75°  or  80°  F.  by  the  addition  of  ice  or 
cold  water.  The  duration  of  the  bath  should 
not  be  more  than  ten  minutes,  constant  fric- 
tion being  maintained  during  the  entire 
process. 

Basin  bathing  for  fever. — Add  eight  ounces 
of  alcohol  to  a  quart  of  water  at  a  tempera- 
ture of  70°  F.  The  child  is  stripped  and 
covered  with  a  flannel  blanket,  and  the  entire 
body  sponged  with  this  solution  for  ten  or 
fifteen  minutes. 

Either  the  tub-bath  or  the  basin-bath  may 
be  used  by  the  mother  in  case  of  sudden  high 
fever— 104°  to  105°  F. — before  the  physician 
arrives.  She  should  be  so  instructed. 

Bathing  for  corn-fort  in  hot  weather. — The 
basin-bath  and  tub-bath  may  also  be  used 
as  a  means  of  relief  during  very  hot  weather. 
One  or  two  basin-baths  a  day,  with  a  tub- 
bath  at  bedtime  during  this  trying  season, 
will  give  the  child  much  relief,  and  help  him 
to  pass  safely  through  it.  The  very  young 
feel  the  extreme  heat  most  acutelv,  and 


Baths 


121 


endure  it  with  difficulty.  I  know  of  nothing 
else  that  will  give  a  restless,  uncomfortable, 
heat-tormented  child  such  a  refreshing  sleep 
as  will  a  cool  basin-bath. 

Mustard  bath. — A  mustard  bath  is  pre- 
pared by  adding  a  heaping  tablespoonful  of 
mustard  to  six  gallons  of  warm  water.  One 
of  the  uses  of  the  mustard  bath  is  in  the  treat- 
ment of  convulsions;  it  will  be  found  useful 
also  for  nervous  children  who  sleep  badly. 
Two  or  three  minutes  in  the  mustard  water, 
followed  by  a  quick  rubbing  immediately 
before  going  to  bed,  is  oftentimes  all  that 
will  be  required  to  induce  refreshing  sleep. 

Brine  bath. — A  brine  bath — an  even  table- 
spoonful  of  salt  to  one  gallon  of  water— is  of 
great  service  with  very  delicate,  poorly  nour- 
ished children.  Its  action  is  that  of  a  tonic. 
If  the  child  is  thoroughly  soaped  and  washed 
with  plain  water,  and  then  immersed  in  the 
brine  bath,  no  further  tubbing  is  necessary. 
The  child  should  be  kept  in  the  bath  for  five 
or  ten  minutes,  constant  friction  being  con- 
tinued during  the  entire  time. 

Soda  bath. — The  soda  bath  is  of  some  service 
in  cases  of  prickly  heat  from  which  many 
children  suffer  during  the  summer.  A  table- 


122  Earache 

spoonful  of  bicarbonate  of  soda  should  be 
added  to  each  half-gallon  of  water  used.  The 
temperature  of  the  water  should  be  that  to 
which  the  child  is  accustomed.  From  two 
to  four  minutes  in  the  water  suffices.  There 
should  be  little  or  no  friction  of  the  skin.  The 
child  should  be  dried  with  soft  towels. 

Bran  bath. — The  bran  bath  also  is  of  service 
in  prickly  heat.  One  cup  of  bran  is  mixed 
with  the  water  in  the  bath-tub  and  the  same 
method  employed  as  for  the  soda  bath. 

Starch  bath. — The  starch  bath  also  is  useful 
in  prickly  heat.  One-half  cupful  of  pow- 
dered laundry  starch  is  mixed  with  the  water 
in  the  bath-tub,  and  the  same  method  em- 
ployed as  for  the  soda  bath. 

Hot  bath. — Place  the  child  for  from  three 
to  five  minutes  in  water  which  has  been  raised 
to  a  temperature  of  105°  to  110°  F.  Con- 
stant friction  of  the  extremities  is  maintained 
while  in  the  water. 

EARACHE 

Infants  and  young  children  are  very  sus- 
ceptible to  attacks  of  earache.  They  usually 
occur  in  children  who  are  suffering  from  some 


Earache  1 23 

inflammatory  condition  of  the  throat  or  nose. 
Such,  however,  is  not  necessarily  the  case. 
I  have  seen  earache  in  children  who  appar- 
ently were  in  perfect  health.  In  the  very 
young  the  only  symptoms  of  the  trouble  may 
be  restlessness,  fever,  which  is  usually  pres- 
ent, and  pain,  which  is  manifested  by  crying. 
I  have  repeatedly  seen  an  attack  so  severe 
as  to  cause  an  infant  to  shriek  with  pain, 
without  any  sign  to  locate  the  trouble.  An 
older  child,  in  addition  to  the  above,  will 
usually  raise  the  hand  to  the  side  affected 
or  point  to  the  pain ful  ear.  The  child  usually 
is  much  disturbed  if  the  ear  is  touched  or 
manipulated  in  any  way.  While  severe  pain 
is  the  rule,  it  may  be  absent;  there  may  be 
loss  of  appetite,  high  fever,  and  restlessness 
for  three  or  four  days  with  no  other  sign  of 
illness,  and  no  evidence  whatever  of  pain, 
when  suddenly  one  discovers  a  yellowish 
discharge  from  the  ear,  with  temporary  or 
permanent  relief  from  the  symptoms. 

In  case  of  an  attack  of  earache,  dry  heat 
is  of  much  service.  Rest  the  ear  on  a  hot- 
water  bag,  or  apply  a  salt  bag.  made  by  sew- 
ing together  two  pieces  of  muslin  about  three 
bv  five-  inches  in  sixe  and  filline  it  one-half 


124  Earache 

full  with  salt.  The  bag  and  contents  are 
then  pressed  flat,  heated,  and  applied  to  the 
ear,  the  salt  retaining  the  heat  for  a  long 
time.  Another  device  is  to  fill  the  finger  of 
an  old  glove  with  salt,  heat  it,  and  place  the 
tip  in  the  ear.  As  an  extra  precaution  the 
mother  or  nurse  should  first  test  it  in  her  own 
ear.  A  douche  at  110°  F.  may  also  be  of 
considerable  service  in  these  cases;  in  my 
experience,  earache  is  best  relieved  by  this 
means.  The  child  should  be  pinned  in  a 
sheet,  and  lie  on  its  back,  with  its  head  on  a 
level  with  or  a  little  lower  than  the  body. 
A  basin  protected  with  a  towel  or  absorbent 
cotton  is  placed  under  the  ear.  One  assist- 
ant is  required  to  steady  the  head,  as  the 
child  will  be  sure  to  struggle.  The  douche 
bag — an  ordinary  fountain  syringe — should 
be  held  not  more  than  two  feet  above  the 
child's  head.  From  one  to  two  pints  of  water 
may  be  needed.  The  tip  of  the  syringe  is 
placed  about  one-quarter  of  an  inch  from  the 
orifice  of  the  canal  and  the  water  is  allowed 
to  flow  into  the  ear  until  the  child  is  relieved 
or  until  the  bag  is  empty.  Such  a  douche 
may  be  repeated  every  hour  until  medical 
aid  arrives. 


Care  of  the  Eyes  125 

Earache  is  usually  due  to  the  presence  of 
pus  or  other  fluid  behind  the  drum  mem- 
brane. This  causes  pressure  within  the  ear 
which  may  require  a  slight  operation  for  its 
relief. 

THE  CARE  OF  THE  EYES 

The  eyes  should  always  be  well  protected 
from  the  sunlight,  the  young  infant  never 
being  allowed  to  lie  with  a  bright  light  from 
a  window  streaming  into  its  face. 

The  eyes  should  be  washed  once  daily  with 
plain  boiled  water.  A  piece  of  soft  old  linen 
should  be  used  and  immediately  burned. 
Before  touching  the  eyes  for  any  purpose, 
the  hands  must  be  washed  with  hot  water 
and  soap. 

No  other  home  treatment  of  the  eyes  is 
allowable,  however  slight  the  ailment.  The 
custom  of  putting  breast-milk  into  the 
eyes  cannot  be  too  strongly  condemned. 
Teas  of  various  kinds  and  proprietary 
or  home-made  eye-washes  should  never 
be  used.  Over  90  per  cent,  of  the  cases 
of  blindness  develop  during  early  life,  nearly 
all  being  due  to  neglect  or  bad  manage- 
ment. 


i26  Dentition 

DENTITION 

Much  has  been  written  about  the  process 
of  teething.  Nearly  all  the  ills  of  childhood, 
other  than  the  contagious  diseases,  have  been 
attributed  to  this  cause.  Not  only  the  laity, 
but  physicians,  are  often  inclined  to  attribute 
this  or  that  ailment  to  teething.  Many  a 
diagnostic  puzzle  has  been  smothered  under 
the  diagnosis  of  dentition.  Observations 
covering  the  teething  period  of  several  thou- 
sand children  in  institution,  out-patient, 
and  private  work,  among  all  classes  and 
conditions  of  children,  have  taught  me  to 
divide  teething  babies  into  three  groups:  the 
breast-fed,  the  well-managed  bottle-fed,  the 
badly  fed. 

The  breast-fed. — In  the  great  majority  of 
the  breast-fed,  the  teeth  appeared  at  the 
proper  time,  with  little  or  no  disturbance. 
Perhaps  there  was  a  period  of  irritability  and 
restlessness  for  a  few  days  before  the  teeth 
came  through.  In  many,  the  teeth  appeared 
without  the  slightest  inconvenience,  and 
that  a  tooth  had  been  cut  was  discovered 
while  washing  or  dressing  the  baby.  In  a 
very  few  breast-fed  babies  there  were  distinct 


Dentition  127 

irritability  and  restlessness,  with  fever  and  a 
slight  diarrhoea,  all  of  which  subsided  when 
the  teeth  appeared. 

The  well-managed  bottle-fed,  such  as  were 
given  cows'  milk  and  cream,  properly  pre- 
pared and  diluted,  teethed,  as  a  rule,  without 
inconvenience.  Some  showed  a  tendency 
to  slight  gastrointestinal  disturbance,  which 
was  relieved  by  diet  and  simple  medication. 
The  cases  which  occasionally  developed 
severe  intestinal  disturbances  were  those 
which  cut  the  first  molars  or  several  other 
teeth  at  one  time  during  the  hot  weather. 
Such  infants  must  be  kept  on  a  very  light 
diet  until  the  teeth  are  through,  or  until  the 
onset  of  colder  weather. 

The  badly  fed.' — These  were  nearly  all 
bottle-fed.  They  were  given  cows'  milk 
improperly  prepared  or  at  too  frequent  inter- 
vals. Only  condensed  milk  and  the  pro- 
prietary foods  had  been  given  some  of  these 
infants.  To  this  class  belong  the  great  num- 
ber of  infants  who  are  given  bread,  meat, 
potatoes,  and  sweets  before  the  digestive 
organs  are  ready  for  such  food.  It  is  these 
badly  fed,  debilitated,  rachitic  infants  who 
are  said  to  "teeth  hard."  They  teeth  late, 


128  Dentition 

cut  several  teeth  at  one  time,  and  have  at- 
tacks of  convulsions,  diarrhoea,  and  vom- 
iting during  the  teething  period.  There  is 
no  doubt  that  the  alimentary  tract  is  pre- 
disposed to  troubles  of  a  catarrhal  nature 
during  active  dentition.  If  the  baby  has 
been  properly  fed  and  is  in  fair  health,  this 
tendency  is  so  slight  that  it  probably  will  not 
be  noticed.  If,  on  the  other  hand,  the  diges- 
tive tract  is  weakened  from  abuse,  vomiting 
and  diarrhoea  often  result.  The  majority  of 
children  who  belong  to  the  third  group  are 
rachitic,  and  rickets  always  mean  enfeebled 
resisting  powers.  Rachitic  children  teeth 
late.  A  rachitic  boy  under  my  observation 
cut  his  first  tooth  during  the  ninth  month, 
and  with  the  eruption  of  this  tooth  and  with 
each  of  the  five  that  appeared  at  intervals  of 
two  or  three  weeks  during  the  next  five 
months,  an  attack  of  vomiting  and  diarrhoea 
occurred,  each  attack  subsiding  when  the 
tooth  pierced  the  gum. 

Irritability  and  restlessness,  slight  fever 
and  gastro-intestinal  derangements,  were 
the  only  unpleasant  effects  of  dentition  in 
any  of  my  patients  who  were  in  fair  health. 
The  irritability,  restlessness,  and  fever  ap- 


Dentition  129 

peared  to  be  due  directly  to  dentition.  Indi- 
rectly, teething  may  be  a  factor  in  gastro- 
intestinal derangements.  The  process  may 
be  painful,  the  digestive  organs  fail  to  act 
properly,  and  trouble  follows.  I  have  never 
known  dentition  to  cause  bronchitis,  eczema, 
or  skin  eruptions  of  any  kind. 

The  opinion  is  very  general  among  the 
ignorant,  that  bronchitis  needs  no  treatment, 
and  that  diarrhoea  is  beneficial  during  the 
teething  process.  These  beliefs,  equally 
dangerous,  have  been  the  cause  of  an  incal- 
culable amount  of  harm:  as  the  result,  many 
lives  are  lost  yearly.  I  have  time  and  again 
seen  children  die  with  summer  diarrhoea  who 
were  brought  for  treatment  when  no  hope 
could  be  given.  The  mother  had  been  told 
and  believed  that  diarrhoea  was  beneficial 
to  the  teething  child,  and  that  if  the  diarrhoea 
were  stopped  the  child  would  be  thrown  into 
convulsions. 

When  the  form  of  a  tooth  can  be  made 
out  pressing  on  the  gum,  and  the  child  is 
fretful  and  feverish,  the  digestive  capacity 
is  lessened,  as  previously  mentioned.  When 
such  is  the  case  the  nourishment  should  be 
temporarily  reduced  one-half  by  the  addition 


130  The  Teeth 

of  boiled  water.  If  the  child  is  breast-fed, 
the  nursing  period  should  be  reduced  to  five 
or  six  minutes,  and  boiled  water  given  to 
drink  between  feedings.  If  a  tooth  is  trying 
to  force  its  way  through  a  thick,  resistant 
gum,  a  great  deal  of  pain  and  discomfort 
will  be  spared  the  child  if  the  tooth  is  assisted 
in  its  progress.  This  is  best  accomplished 
by  the  use  of  a  clean  towel,  which  is 
placed  over  the  finger  and  vigorous  fric- 
tion brought  to  bear  over  the  sharp  edge  of 
the  tooth.  It  is  quicker  and  less  painful 
than  lancing,  and  the  gum  will  not  close  over 
the  tooth. 

THE  TEETH 

Twenty  teeth  comprise  the  first  set.  In 
the  well  child  the  first  tooth  usually  appears 
between  the  sixth  and  the  eighth  months; 
the  first  teeth  may,  however,  in  perfectly 
normal  cases,  come  earlier  or  much  later. 
I  have  known  well,  vigorous  children  who  did 
not  get  a  tooth  until  the  thirteenth  month. 
The  first  teeth  are  usually  the  two  lower 
central  incisors;  generally  the  four  upper 
incisors  and  the  two  lower  lateral  incisors 


The  Teeth  131 

appear  between  the  eighth  and  the  tenth 
months.  The  first  four  molars  appear  be- 
tween the  twelfth  and  the  fifteenth  months; 
the  eye-  and  stomach-teeth  between  the 
eighteenth  and  the  twenty-fourth  months; 
the  four  posterior  molars  between  the  twenty  - 
fourth  and  the  thirtieth  months.  This  regu- 
larity in  the  appearance  of  the  teeth  is  by  no 
means  constant  even  in  well  children.  I 
have  in  several  instances  seen  the  upper 
lateral  incisors  appear  first.  In  delayed 
dentition  the  teeth  are  very  apt  to  appear 
irregularly. 

The  care  of  the  teeth.' — As  soon  as  the  teeth 
appear  they  require  attention.  Until  the 
second  year  is  reached  the  mouth  should  be 
washed  out  at  least  twice  a  day  with  a  solu- 
tion of  boracic  acid— one  ounce  to  a  pint  of 
water.  This  can  best  be  done  by  means 
of  absorbent  cotton  \vound  around  the  tip  of 
a  clean  index  finger  and  afterward  dipped 
into  the  solution,  when  it  should  be  applied 
with  gentle  friction  to  the  gums  and  teeth. 
When  a  child  is  two  years  old  it  is  well  to 
begin  the  use  of  a  soft  tooth-brush,  and  a 
simple  tooth  powder  composed  of  the  follow' 
ing  ingredients: 


i32  The  Teeth 

Precipitated  chalk,  i  ounce. 
Bicarbonate  of  soda,  i  drachm. 
Oil  of  wintergreen,  a  few  drops. 

The  child  should  also  be  instructed 
early  as  to  the  proper  use  of  a  quill  tooth- 
pick. 

The  milk-teeth  are  lost  between  the  sixth 
and  eighth  years.  They  should  not  decay 
but  fall  out  or  be  forced  out  by  the  second 
set.  The  teeth  of  every  child  over  two  years 
of  age  should  be  examined  by  a  dentist  every 
six  months.  If  cavities  are  discovered  in 
the  first  teeth  they  should  be  filled  with  a 
soft  filling. 

The  permanent  teeth. — The  permanent  set 
comprises  thirty-two  teeth.  The  second 
dentition  begins  about  the  sixth  year,  and  is 
usually  completed  about  the  twentieth  year, 
although  it  may  be  delayed  several  years 
later.  The  permanent  teeth  appear  in  some- 
what the  following  order: 

First  molars sixth  year . 

Central  incisors. .  .  .sixth  to  seventh  year. 
Lateral  incisors..  .  .seventh  to  eighth  year. 

First  bicuspids ninth  to  tenth  year. 

Second  bicuspids  .  .ninth  to  tenth  year. 


The  Hair  133 

Canines eleventh  to  twelfth   year. 

Second  molars thirteenth  to  fifteenth  year. 

Third  molars after  the  eighteenth  year. 

THE  HAIR 

Whether  the  child  should  wear  the  hair 
long  or  short  is  a  point  upon  which  the  doctor 
is  likely  to  give  unsought  advice.  There  are 
two  reasons  why  a  child's  hair  should  be  kept 
short  : 

1 .  From  the  standpoint  of  comfort.     Dur- 
ing the  hot  months  children  perspire  very 
freely  both  by  day  and  by  night.     The  heavy 
mass  of  hair  which  falls  about  the  neck  and 
shoulders  adds  greatly  to  the  warmth  and 
discomfort.     I  find  that  many  children  with 
long  hair  are  poor  sleepers  and  are  irritable 
and  hard  to  please  when  awake.     In  winter 
the  child  is  very  apt  to  perspire  about  the 
head  and  neck  in  active  play,  and  runs  a 
greater  risk  from  exposure  than  if  the  exces- 
sive perspiration  did  not  occur. 

2.  The   hair   should    be    kept    reasonably 
short,  because  then  the  scalp   can   be   kept 
in    a     much     healthier    condition,     and     a 
much  better  growth  of  hair  assured  in  later 
life. 


i34  Nursery-Maids 

NURSERY-MAIDS 

The  mother  who  can  afford  the  expense 
of  a  helper  should  never  take  entire  charge 
of  her  baby ;  nor  should  she  share  this  duty 
with  the  maid  of  all  work  if  better  assistance 
can  be  secured.  The  child  requires  more 
attention  than  any  one  person  should  bestow. 
If  one  person  is  constantly  in  charge  of  a 
child  it  will  either  be  neglected  or  the  health 
of  the  mother  or  nurse  will  suffer  and  conse- 
quently her  services  be  less  efficient.  Many 
a  young  mother  has  sacrificed  her  health 
because  of  a  false  sense  of  duty  in  this  respect. 
The  close  confinement  in  itself  would  ruin 
her  health  and  make  her  prematurely  old. 
The  children  that  are  born  later  have  less 
vigor,  are  more  susceptible  to  illness,  and 
start  out  handicapped  in  life  as  a  conse- 
quence. The  constant  attention  of  the 
mother  is  not  necessary ;  in  fact,  it  is  often 
injurious  to  the  child.  She  is  apt  to  handle 
the  child  too  much,  to  overentertain  it.  A 
bright  young  woman  should  be  secured  as 
soon  as  the  monthly  nurse  leaves,  to  as- 
sist in  the  care  of  the  child.  If  she  is  a 
trained  nursery-maid  who  has  had  previous 


The  Trained  Nurse  135 

experience  of  the  right  kind,  she  will  be 
invaluable.  In  case  a  trained  assistant  is 
not  to  be  obtained,  any  intelligent  'young 
woman  of  cleanly  habits,  and  who  is  fond 
of  children,  may  be  trained  at  home  in  a 
few  weeks. 

THE  TRAINED  NURSE 

If  possible,  a  trained  nurse  should  be  em- 
ployed in  every  severe  illness  of  childhood. 
She  may  alternate  with  the  mother  or  nursery- 
maid in  the  care  of  the  child.  If  the  case  is 
very  urgent,  two  trained  nurses  should  be 
employed.  The  nurse  must  never  be  ex- 
pected to  work  for  more  than  twelve  con- 
secutive hours.  A  tired  nurse  should  never 
be  in  charge  of  a  sick  baby. 

The  employment  of  a  trained  nurse  does 
not  mean  that  the  mother  may  not  perform 
many  little  offices  for  the  patient,  but  the 
trained  nurse  should  be  in  charge,  and  her 
opinions  respected. 

Many  an  excellent  mother  makes  a  very 
poor  nurse  for  her  own  child  during  a  severe 
illness.  Her  great  interest  and  anxiety 
impairs  her  judgment.  She  is  apt  to  become 
confused  and  fail  to  meet  emergencies.  A 


136  The  Trained  Nurse 

mother  who'  is  useless  for  a  like  office  in  her 
own  household  oftentimes  makes  an  excel- 
lent nurse  for  her  friend's  child.  The  mother 
in  the  capacity  of  a  nurse  for  her  own  infant 
is  apt  to  fail  under  some  of  the  following 
conditions:  She  is  inclined  to  put  more  cloth- 
ing on  the  baby  than  the  doctor  advised.  If 
a  window  is  the  means  of  ventilation,  she  has 
a  strong  inclination  to  close  it  a  little  beyond 
the  point  which  the  physician  marked  with 
a  lead-pencil.  The  temperature  of  the  sick- 
room is  often  kept  higher  than  is  good  for 
the  baby.  Offices,  the  performance  of  which 
cause  the  child  discomfort,  are  often  not 
thoroughly  attended  to,  such  as  washing  the 
eyes,  sponging  off  the  patient  in  fever,  syring- 
ing the  ears,  and  adhering  to  a  greatly  re- 
stricted diet.  These,  and  a  few  like  offences, 
are  pardonable  in  the  mother,  but  they  show 
us  that  in  a  severe  illness  trained  help  is  indis- 
pensable. Further,  I  am  very  sorry  to  say 
that  sometimes  influences  against  carrying 
out  the  physician's  directions  in  important 
particulars  are  successfully  brought  to  bear 
upon  the  mother  by  well-meaning  relatives 
and  friends  who  possess  no  knowledge  what- 
ever of  the  illness  in  question. 


Adenoids  137 

ADENOIDS 

Adenoids  are  tumor-like  growths  that 
develop  at  the  junction  of  the  upper  portion 
of  the  posterior  pharyngeal  wall  and  the 
vault  of  the  pharynx.  They  may  simply 
cover  the  surface  of  the  parts  in  a  spongy 
layer  or  they  may  fill  the  entire  naso-pharyn- 
geal  space,  completely  blocking  the  passage 
from  the  nose  to  the  throat.  They  are  not 
to  be  considered  as  new  growths,  but  rather 
as  hypertrophies,  or  overgrowths,  of  the 
mucous  glands  and  tissues  of  the  parts.  They 
may  vary  in  size  from  a  flaxseed  to  a  walnut. 
Among  the  causes  of  adenoids  may  be  men- 
tioned the  use  of  the  "pacifier"  in  infancy, 
repeated  "colds"  in  the  head,  breathing 
the  dust-laden  air  of  our  large  cities,  mal- 
nutrition, and  unhygienic  living.  While 
the  taking  of  cold  is  a  factor  in  the  de- 
velopment of  adenoids,  my  observation 
is  that  predisposition  plays  an  important 
part.  Many  children  have  a  tendency  to 
glandular  enlargement;  in  fact,  in  New  York 
City,  a  large  percentage  of  the  children  under 
ten  years  of  age  have  adenoids.  In  a  child 
under  two  years  of  age  the  naso-pharyngeal 


138  Adenoids 

space  is  a  very  narrow  slit;  and  since  the 
majority  of  children  up  to  the  eighteenth 
month  of  life  are  sucking  on  something  the 
greater  part  of  their  waking  hours,  the  soft 
palate  is  forced  back  against  the  posterior 
pharyngeal  wall,  interfering  with  the  drain- 
age of  the  parts,  and  on  account  of  the  fric- 
tion of  the  opposed  surfaces  congestion  and 
irritation  follow,  resulting  finally  in  a  general 
hypertrophy. 

Very  young  children  may  have  adenoids. 
The  youngest  patient  that  I  have  operated 
upon  was  eight  months  old.  The  majority 
of  cases  occur  in  children  from  eighteen 
months  to  six  years  of  age.  A  slight  amount 
of  adenoid  growth  may  cause  no  symptoms. 
A  few  summers  ago  I  examined  the  throats 
of  forty  children  between  the  ages  of  two  and 
five  years,  who  came  for  treatment  for  other 
conditions.  In  thirty-seven,  adenoids  were 
present.  In  twelve,  operation  was  advised, 
and  in  five,  operation  was  performed.  In 
fifteen  the  growths  were  not  sufficiently  large 
to  justify  operation  in  the  absence  of  annoy- 
ing or  dangerous  symptoms. 

The  presence  of  adenoids  is  perhaps  most 
often  manifested  by  symptoms  of  chronic 


Adenoids  139 

cold  in  the  head.  There  is  a  great  deal  of 
discharge  from  the  nose.  The  child  has 
snuffles  all  winter.  During  summer  there  is 
little  if  any  trouble.  The  child  is  said  to 
take  cold  easily.  The  slightest  exposure 
will  cause  a  running  at  the  nose.  Cough  is 
often  associated  with  the  nasal  discharge, 
or  it  may  follow  it.  The  cough  is  worse  at 
night;  in  fact,  it  often  is  not  noticed  until 
the  child  goes  to  bed.  Such  a  cough  was 
formerly  known  as  "the  nervous  cough"  or 
"the  stomach  cough." 

If  the  growths  are  large,  we  have  mouth- 
breathing  added  to  the  other  symptoms. 
The  child  breathes  through  the  mouth  both 
day  and  night  for  the  reason  that  the  breath- 
ing space  through  the  nose  is  choked.  The 
night  mouth-breathing  gives  rise  to  snoring; 
some  of  these  children  snore  like  adults. 
Almost  every  snoring  child  will  be  found 
to  have  either  adenoids  or  enlarged  tonsils, 
or  both. 

In  advanced  cases  the  appearance  of  the 
face  of  the  patient  is  characteristic.  The 
habitual  open  mouth  gives  the  face  a  stupid 
expression.  In  fact,  such  children  are  apt 
to  be  mentally  dull.  The  nostrils  are  small 


140  Enlarged  Tonsils 

and  pinched.  The  upper  lip  is  usually  thick- 
ened. The  voice  is  also  affected ;  there  is  a 
decided  nasal  twang,  and  articulation  is 
sometimes  impaired.  The  child  has  trouble 
in  blowing  his  nose.  Occasionally  adenoids 
are  the  cause  of  very  severe  nosebleed.  In 
a  small  proportion  of  the  cases  hearing  is 
impaired.  Bed-wetting  may  be  due  to  ade- 
noids. Recently  a  writer  reported  seven 
cases  of  inveterate  bed-wetters,  all  cured  by 
the  removal  of  the  adenoids.  These  children 
are  more  susceptible  to  diphtheria,  and  if 
they  contract  the  disease  it  is  apt  to  be  more 
severe.  For  adenoids  of  any  degree  of  sever- 
ity, complete  removal  is  the  only  treatment. 
Sprays  and  the  various  local  applications  are 
absolutely  worthless.  The  operation  is  prac- 
tically without  danger. 

ENLARGED  TONSILS 

Chronic  enlargement  of  the  tonsils  is  almost 
always  associated  with  adenoids  and  is  re- 
sponsible in  a  degree  for  their  presence.  We 
see  many  cases  of  adenoids,  however,  in 
which  there  is  no  tonsillar  enlargement. 
Predisposition  and  repeated  attacks  of  acute 
tonsillitis  lead  to  chronic  enlargement  of  the 


Milk  in  Infants'  Breasts       141 

tonsils.  Enlarged  tonsils,  when  associated 
with  adenoids,  do  not  change  the  character 
of  the  symptoms  of  adenoids  except  to  aggra- 
vate them ;  therefore  they  should  be  removed 
as  well  as  the  adenoids.  All  other  treatment 
in  young  children  is  useless.  The  operation 
in  skilful  hands  may  be  said  to  be  practically 
without  danger.  Parents  always  dread  the 
operation,  but  the  relief  afforded  the  suffering 
child,  and  the  knowledge  that  a  serious  ob- 
stacle to  the  child's  growth  and  development 
has  been  removed,  will  repay  them  for  their 
hours  of  anxiety.  Gargles  and  sprays  are  of 
little  or  no  value  in  chronic  enlargement  of 
the  tonsils. 

MILK  IN  INFANTS'  BREASTS 

It  is  not  at  all  uncommon  for  an  infant's 
breasts,  at  birth,  to  contain  a  substance 
resembling  milk.  When  this  occurs,  the 
breasts  are  to  be  left  alone  and  the  milk  will 
disappear.  It  is  quite  a  common  belief 
among  hospital  and  dispensary  patients  that 
the  milk  should  be  pressed  out.  This  is  very 
wrong.  In  two  cases  I  have  known  abscesses 
to  develop  after  this  treatment  by  a  midwife, 
and  in  one  case  the  child  nearlv  lost  its  life. 


142     How  to  Take  Temperature 

TEMPERATURE,  AND  HOW  TO  TAKE  IT 

The  normal  rectal  temperature  of  an  infant 
varies  between  98.5°  and  99.5°  F.  The  tem- 
perature should  be  taken  in  the  rectum.  The 
mouth  is  impossible,  the  groin  and  axilla 
absolutely  unreliable.  The  child  should  lie 
on  its  stomach  either  in  its  bed  or  across  the 
nurse's  lap.  Both  the  anus  and  the  bulb  of 
the  thermometer  should  be  well  oiled.  The 
bulb  is  passed  into  the  rectum  so  that  the 
mercury  c a  nnot  be  seen  and  allowed  to  remain 
three  minutes.  If  the  child  kicks  or  struggles 
some  one  should  hold  its  legs.  Mothers  are 
often  disturbed  because  of  a  persistence  of 
the  temperature  between  99.5°  and  100.5°  ^- 
While  such  a  degree  cannot  be  considered 
normal,  it  does  not  follow  that  it  is  of  any 
consequence.  This  slight  elevation  may 
follow  the  acute  illnesses  such  as  grippe, 
pneumonia,  and  scarlet  fever,  and  may  con- 
tinue for  weeks,  without  any  harm  resulting. 
Nervous,  irritable  infants  will  often  range 
at  1 00°  F.  for  weeks  at  a  time.  In  like 
manner  children  who  are  stimulated  by 
playing  with  older  children  or  with  adults 
will  often  develop  a  rise  in  temperature 


Appetite  1 43 

which  subsides  as  soon  as  the  cause  is  re- 
moved. 

The  thermometer  should  be  washed  with 
a  one-per-cent  solution  of  carbolic  acid  after 
using. 

APPETITE 

It  may  be  safely  said  that  a  well,  vigorous 
child  is  a  hungry  child,  and  nearly  every 
child  may  be  made  thoroughly  hungry  three 
times  a  day  by  suitable  food  at  proper  in- 
tervals. The  children  who  come  under  my 
care  for  poor  appetite,  without  evidence  of 
disease  to  account  for  it,  are,  almost  without 
exception,  improperly  fed.  They  are  often 
given  unsuitable  food  at  meal-time,  when 
they  are  loaded  down  with  sweets  and  pas- 
tries; but  the  chief  error  is  eating  between 
meals.  This  habit  has  ruined  more  appe- 
tites and  has  been  the  cause  of  more  stomach 
disorders  than  any  other  one  factor.  It  is 
surprising  what  a  large  amount  of  candy, 
sweet  crackers,  and  the  like  are  disposed  of 
in  many  households.  Even-  year  I  am  called 
upon  to  treat  cases  of  loss  of  appetite  in  "  run- 
abouts" from  eighteen  months  to  three  vears 


144  Appetite 

of  age,  who  have  what  I  have  designated  the 
milk  habit.  These  children  drink  from  five 
to  six  pints  of  milk  a  day,  and  refuse  all  other 
food.  The  milk  satisfies  the  appetite  but 
does  not  furnish  the  nourishment  required 
for  the  rapid  growth  that  takes  place  at  this 
time,  and  the  child  in  consequence  suffers 
from  malnutrition.  He  is  pale,  thin,  and 
sallow  in  appearance,  the  sleep  is  poor,  and 
the  child  is  irritable  and  hard  to  please.  We 
also  see  children  at  this  age  who  suffer  from 
improper  nutrition  on  account  of  too  re- 
stricted a  diet.  They  take  other  food  than 
milk,  but  not  in  sufficient  quantity  or  variety. 
Some  will  refuse  all  kinds  of  vegetables, 
others  will  refuse  all  kinds  but  one  or  two; 
some  will  not  take  stewed  fruit;  others  will 
not  touch  meat  or  eggs,  no  matter  how  they 
may  be  prepared ;  some  will  take  but  one 
cereal,  others  will  refuse  cereals  altogether. 
The  child's  whims  in  these  respects  must 
never  be  catered  to.  lie  is  to  take  what  is 
placed  before  him  or  go  without  until  the 
next  meal.  Likes  and  dislikes  for  various 
articles  of  diet  are  largely  a  matter  of  edu- 
cation, and  the  child  may,  and  should,  be 
taught  to  eat  everything  that  is  good  for 


Appetite  145 

him.  A  little  firmness  in  compelling  him 
to  go  hungry  for  a  few  hours  will  soon  do 
away  with  any  childish  fancy,  which  may 
be  the  cause  of  considerable  harm.  These 
children  are  rapidly  growing,  and  for  proper 
growth  and  development  require  a  mixed 
diet.  If  the  child  is  wedded  to  milk  and 
refuses  everything  else,  the  milk  must  tem- 
porarily be  discontinued.  Some  children 
with  a  poor  appetite  for  solids  will  drink  a 
glass  or  two  of  milk  at  the  commencement 
of  a  meal.  This  satisfies  the  appetite  for  the 
time  and  nothing  more  will  be  taken.  With 
such  children  the  milk  must  be  kept  out  of 
sight  until  the  meal  is  completed,  when  one- 
half  pint  may  be  given. 

I  have  treated  quite  a  number  of  cases  of 
poor  appetite  and  milk  appetite  in  children 
otherwise  well,  in  the  following  manner: 
The  child  is  undressed  and  placed  in  bed 
and  put  under  the  care  of  one  person  as 
though  he  were  very  ill.  The  object  in 
placing  the  patient  in  bed  is  to  prevent  his 
getting  food  other  than  that  ordered.  He 
is  allowed  water  to  drink  in  plenty.  For 
the  first  clay  he  is  given  four  ounces  of  plain 
chicken  or  mutton  broth  every  three  hours. 


146  Appetite 

The  second  day  he  receives  six  to  eight  ounces 
of  the  broth  at  three-hour  intervals.  On 
the  third  day  he  is  usually  ravenously  hun- 
gry and  he  is  then  given  three  or  four  good 
meals,  when,  if  he  has  any  special  dislike 
for  any  article  of  diet,  that  is  included  in 
the  first  meal.  In  such  cases  it  is  surprising 
with  what  favor  the  formerly  despised  cereal, 
meat,  egg,  or  vegetable  will  be  looked  upon, 
and  it  will  thereafter  have  a  cherished  place 
in  the  child's  heart.  Some  mothers  will  not 
be  a  party  to  such  heartless  treatment,  as 
they  are  inclined  to  call  it,  but  this  is  a  wrong 
view  to  take  of  it.  A  complete  change  of 
diet  for  a  clay  or  two  would  often  be  of  benefit 
to  all  of  us.  With  the  child  the  advantage 
derived  from  thus  learning  to  enjoy  a  mixed 
diet  will  favorably  influence  his  health  for 
the  rest  of  his  life.  Change  of  climate,  fresh 
air,  out-of-door  exercise,  suitable  food  at 
regular  intervals — all  favorably  affect  the 
appetite. 

Children  who  over-exert  themselves  at 
school  or  at  play  or  who  are  easily  excited 
and  have  plenty  of  opportunity  for  excite- 
ment often  suffer  from  loss  of  appetite.  The 
management  of  these  cases  is  to  remove  the 


Habits  147 

source  of  the  trouble,  whatever  it  may  be. 
An  excellent  means  of  bringing  these  chil- 
dren to  a  normal  condition  is  an  enforced 
rest  for  one  and  one-half  hours  after  the 
noon-day  meal. 

HABITS 

The  Pacifier;  Ear-Pulling;  Masturbation 

Babies  acquire  habits  most  easily  and  at 
a  very  early  age.  Whether  the  habits  are 
good  or  bad  depends  more  upon  the  child's 
attendants  than  upon  the  child  itself.  If 
properly  trained — and  the  training  must 
begin  at  birth — a  baby  will  acquire  the  habit 
of  taking  his  food  at  regular  intervals  by  day 
and  by  night,  and  he  will  also  acquire  the 
habit  of  going  to  sleep  and  waking  at  regular 
intervals.  As  a  result  of  a  careful  regime 
regarding  feeding,  sleep,  bathing,  and  airing, 
and  the  performance  of  its  various  functions 
at  stated  times  every  day,  the  baby  will  soon 
develop  into  a  "little  machine,"  as  one 
mother  called  her  babe.  Such  a  child  causes 
no  trouble  and  thrives  far  better  than  one 
who  is  ted  every  time  he  cries,  day  or  night. 
A  baby  that  requires  constant  entertaining 


148  Habits 

when  awake,  and  that  sleeps  only  when  ex- 
hausted, usually  has  another  bad  habit,— 
that  of  being  held  constantly  in  arms.  A 
baby  should  be  handled  very  little, — just 
enough  to  give  it  exercise.  It  will  learn  to 
amuse  itself  at  a  very  early  age  if  given  an 
opportunity. 

The  "pacifier"  habit — the  habit  of  sucking 
a  rubber  nipple  —  is  an  inexcusable  piece  of 
folly  for  which  the  mother  or  nurse  is  directly 
responsible.  The  habit  when  formed  is 
most  difficult  to  give  up.  The  use  of  the 
"pacifier,"  thumb-sucking,  finger-sucking, 
etc.,  make  thick,  boggy  lips,  on  account  of 
the  exercise  to  which  the  parts  are  subjected. 
They  cause  an  outward  bulging  of  the  teeth 
and  a  narrowing  of  the  jaws,  which  are  not 
conducive  to  personal  attractiveness.  Nature 
has  not  been  so  lavish  of  her  gifts  to  the  great 
majority  of  mankind  that  they  can  afford 
to  trifle  with  her  handiwork.  Furthermore, 
the  "pacifier"  is  often  a  menace  to  health. 
If  there  are  two  or  three  young  children  in 
the  family  it  is  frequently  passed  around 
without  other  means  of  cleansing  than  being 
drawn  a  couple  of  times  across  the  nurse's 
sleeve.  This  novel  method  of  disinfecting 


Habits  149 

the  "pacifier"  may  be  seen  in  actual  use  in 
the  Park  any  pleasant  day,  and  I  have  often 
seen  the  mother  or  nurse  moisten  the  "paci- 
fier" with  her  own  lips  before  giving  it  to 
the  child.  I  have  seen  young  children  fight 
for  the  "pacifier,"  one  taking  it  from  the 
mouth  of  another!  It  may  readily  be  con- 
ceived what  a  boundless  source  of  harm  this 
little  instrument  may  be,  when  every  sort 
of  disease  known  to  childhood  may  be  trans- 
ferred by  it.  Thus  it  may  act  as  a  means  of 
transmitting  tuberculosis,  syphilis,  diphtheria 
and  many  other  ailmentsof  minor  importance. 

Adenoids,  referred  to  in  another  chapter, 
are  often  the  result  of  thumb-sucking  or  the 
use  of  the  "pacifier."  The  pressure  exerted 
in  sucking  forces  the  soft  palate  against  the 
posterior  pharyngeal  wall ;  this  irritates  and 
stimulates  the  glands  of  the  part,  which  in 
time  enlarge,  and  adenoids  develop. 

To  break  the  child  of  the  "pacifier"  habit, 
burn  the  "pacifier"  and  do  not  buy  another, 
as  is  sometimes  done.  For  thuml  i-sucking  and 
finger-sucking,  bandage  the  hands  and  moisten 
the  bandage  occasionally  with  a  solution  of 
quinine.  The  "hand  and  hold  mit  "  (Fig.  oo) 
is  a  useful  means  in  breaking  the  habit. 


150  Habits 

A  few  children  develop  the  ear-pulling 
habit.  It  is  always  one  ear  which  receives 
attention.  Sometimes  it  is  the  lobe  and 
sometimes  the  upper  portion.  The  child 
pulls  on  the  ear  the  greater  portion  of  its 
waking  hours.  As  a  result  of  this  practice, 
I  have  seen  ears  drawn  entirely  out  of  shape. 
Bandaging  the  hands  so  that  the  fingers  can 
not  be  used  to  grasp  the  ear  is  the  best  means 
of  breaking  the  habit.  The  "hand  and  hold 
mit"  may  also  be  used  with  advantage. 

Occasionally  children  are  met  with  who 
have  a  mania  for  placing  foreign  bodies  in 
the  nose  and  ear.  Shoe  buttons  are  the  favor- 
ites, although  beans,  pieces  of  coal,  pebbles, 
and  various  other  kinds  of  buttons  serve  the 
purpose  when  shoe  buttons  are  scarce.  The 
habit  is  best  controlled  by  a  vigorous  spank- 
ing following  each  offence. 

Masturbation  is  one  of  the  most  injurious 
of  habits.  It  consists  in  an  irritation  of  the 
genitals  by  manipulation,  by  leg-rubbing,  or 
by  pressing  the  parts  against  some  pointed 
object.  Under  the  age  of  six  years  mas- 
turbation is  more  common  in  girls  than  in 
boys.  My  youngest  was  a  girl  only  six 
months  old.  If  the  habit  is  not  detected, 


Habits  151 

masturbation  may  be  practised  for  a  long 
time  and  repeated  many  times  a  day.  As  a 
result,  the  child  becomes  irritable,  loses  sleep 
and  weight,  and  is  transformed  into  a  con- 
dition of  mental  and  physical  exhaustion. 

The  formation  of  habits  and  their  cor- 
rection rests  largely  with  the  mother  or 
attendant.  Considerable  stability  is  neces- 
sary for  the  correction  of  a  bad  habit,  or  the 
formation  of  a  good  one.  It  means  several 
prolonged  crying  attacks  on  the  part  of  the 
child  and  perhaps  two  or  three  wakeful 
nights.  To  cure  the  habit  of  masturbation, 
if  the  child  is  under  eighteen  months  of  age, 
the  hands  may  be  bandaged,  or,  what  is 
better,  a  piece  of  tape  may  be  fastened 
around  each  wrist  and  tied  together  at  the 
back  of  the  neck,  making  all  secure  with  a 
safety-pin.  The  pieces  of  tape  should  be 
of  sufficient  length  to  allow  the  child  free 
movement  of  the  hands,  but  not  long  enough 
to  allow  them  to  come  in  contact  with  the 
genitals. 

Leg-rubbing  is  more  frequently  seen  in 
very  young  girl  babies.  In  such  cases  the 
wearing  of  a  thick  napkin  or  of  two  napkins 
will  usually  prevent  the  practice.  In  some 


15 2          The  Normal  Throat 

obstinate  cases  of  leg-rubbing  in  older  girls 
I  have  used  a  "knee  crutch"  with  decided 
success.  In  children  over  two  years  of  age, 
constant  watchfulness  and  vigorous  pun- 
ishment for  each  offence,  combined  with 
medical  treatment,  will  cure  most  cases, 
although  with  some  much  difficulty  will  be 
experienced. 

The  practice  must  be  prevented  and  the 
genitals  brought  to  a  normal  condition,  when 
the  patient  will  soon  forget  the  indulgence. 

THE  NORMAL  THROAT 

Every  mother  should  learn  the  appearance 
of  the  healthy  throat,  and  every  child  should 
be  accustomed  to  throat  examination.  It 
will  soon  learn  that  no  harm  is  intended  and 
force  will  not  be  required.  The  family  phy- 
sician should  demonstrate  to  the  mother  the 
color  of  the  normal  mucous  membrane,  and 
the  size  and  appearance  of  the  tonsils  in 
health.  By  knowing  the  normal  throat  she 
will  be  able  to  recognize  inflammation,  swel- 
ling, and  exudation  in  the  form  of  the  cheesy 
dots  seen  in  tonsillitis,  and  the  membrane 
in  diphtheria.  With  the  first  appearance 
of  exudation  of  any  kind,  medical  aid  should 


How  to  Examine  the  Throat     153 

be  summoned.  No  chances  should  be  taken 
with  these  cases.  I  know  of  fathers  and 
mothers  who  will  never  cease  to  regret  that 
they  did  not  appreciate  the  dangers  of  tem- 
porizing with  what  they  considered  a  "can- 
kerous sore  throat."  Diphtheria  is  most 
insidious  in  its  onset  and  a  sore  throat  should 
never  be  neglected. 

HOW  TO  EXAMINE  THE  THROAT 

(See  Fig.  8.) 

In  order  to  examine  a  baby's  throat  quickly 
and  thoroughly  the  child  must  be  held  in 
front  of  and  at  the  right  side  of  the  attend- 
ant, supported  by  the  attendant's  left  arm 
under  the  buttocks;  the  right  arm,  which  is 
thus  left  free,  is  passed  around  the  child, 
binding  its  arms  to  its  sides.  The  child's 
head  rests  upon  the  right  shoulder  of  the 
attendant. 

The  mother  places  her  left  hand  on  the 
child's  head  to  steady  it  and  with  tongue 
depressor  or  teaspoon  in  her  right  hand  she 
presses  down  the  tongue,  and,  with  the  child 
under  perfect  control,  she  brings  into  view 
the  parts  that  are  to  be  examined.  The 


154  Sprue  and  Thrush 

most  satisfactory  view  can  be  obtained  by 
daylight  before  a  window.  If  the  examina- 
tion is  made  in  the  evening,  a  lamp  or  taper 


FIG.    8.       THE    THROAT    EXAMINATION 

held  by  a  third  party,  a  trille  above  and 
behind  the  mother's  right  shoulder,  will 
furnish  a  satisfactory  illumination. 

SPRUE  AND  THRUSH 

Thrush  consists  of  a  parasitic  growth 
which  appears  on  the  mucous  membrane 
of  the  mouth  in  voung  infants.  The  dis- 


Sprue  and  Thrush  '  155 

ease  makes  its  appearance  in  the  form 
of  small  white  masses  about  the  size  of  a 
pinhead.  The  tongue  and  the  inner  side 
of  the  cheeks  are  favorite  sites  for  the 
growth,  although  in  severe  cases  the  entire 
buccal  cavity  may  be  studded  with  it,  causing 
it  to  look  as  though  finely  curdled  milk  had 
been  scattered  over  the  surface.  The  growth 
is  firmly  adherent,  and  if  removed  forcibly, 
slight  bleeding  results.  It  is  usually  asso- 
ciated with  uncleanliness,  and  occurs,  as  a 
rule,  in  weakly  and  marasmic  nurslings  and 
in  the  bottle-fed,  more  frequently  in  the  lat- 
ter. It  is  rarely  seen  after  the  sixth  month. 

In  an  infant  with  sprue,  there  is  evidence 
of  much  pain  and  discomfort  while  nursing 
or  while  feeding  from  a  bottle.  The  disease 
is  not  contagious.  The  average  case  may 
easily  be  cured  in  a  week,  if  the  directions 
for  the  treatment  are  carefully  carried  out. 
Active  gastro -enteric  disturbances,  such  as 
vomiting  and  diarrhoea,  may  be  associated 
with  sprue,  but  it  is  not  the  rule.  Time  and 
again  I  have  seen  cases  of  sprue  in  which 
there  were  absolutely  no  other  signs  of  the 
disease  aside  from  the  characteristic  mouth 
lesions  and  the  refusal  of  food. 


156  Sprue  and  Thrush 

If  the  means  of  prophylaxis,  which  will  be 
suggested,  are  used  as  the  daily  routine,  the 
disease  will  never  appear. 

If  breast-fed,  the  mother's  nipples  must 
be  washed  with  a  saturated  solution  of  boric 
acid,  and  moistened  with  alcohol,  diluted 
one-half,  which  is  allowed  to  evaporate  before 
each  nursing.  If  bottle-fed,  the  nipple  and 
bottle  should  be  boiled  after  each  nursing, 
the  nipples  turned  inside  out  and  scrubbed 
with  borax  water — one  ounce  of  borax  to  a 
pint  of  water.  Whether  breast-fed  or  bottle- 
fed,  the  mouth  should  be  washed  with  a 
saturated  solution  of  boric  acid  after  each 
nursing.  For  this  purpose  a  generous 
amount  of  absorbent  cotton  is  loosely 
wrapped  around  the  clean  index-finger  of 
the  mother  or  nurse.  This  is  placed  in  the 
cold  solution,  arid  without  pressing  out  the 
water  the  ringer  is  introduced  into  the  child's 
mouth,  and,  in  cases  of  sprue,  brought  gently 
in  contact  with  the  diseased  pails,  first  with 
one  side  and  then  with  the  other,  being 
pressed  upon  the  tongue  and  under  the 
tongue.  It  is  well  to  have  the  child  rest 
on  its  side  or  stomach  so  that  the  fluid  which 
is  pressed  out  by  the  manipulation  of  the 


Stomatitis,  or  Sore  Mouth     157 

cotton  against  the  cheeks  and  jaws  can 
readily  escape  from  the  mouth.  The  wash- 
ing, which  really  amounts  to  an  irrigation, 
can  be  done  in  a  few  seconds,  without  the 
slightest  danger  of  abrading  the  epithelium. 
Internal  medication  is  of  no  value  in  sprue 
except  in  correcting  any  intestinal  derange- 
ment that  may  exist,  with  a  view  to  improv- 
ing the  general  condition.  If  the  bottle 
or  breast  is  refused,  spoon-feeding  for  a  few 
days  may  be  necessary,  and  will  hasten  a 
cure.  If  the  child  is  nursed,  the  mother's 
milk  may  be  drawn  with  a  breast-pump 
(see  page  47),  or  pressed  out  with  the  fingers, 
and  fed  to  the  child.  The  domestic  remedy, 
honey  and  borax,  should  not  be  used  in  any 
of  the  inflammatory  diseases  of  the  mouth 
in  children. 

STOMATITIS,  OR  SORE  MOUTH 

There  are  three  varieties  of  this  disorder — 
the  catarrhal,  the  aphthoiis,  and  the  ulccrativc. 

In  the  catarrhal  form  there  is  redness 
of  the  gums  with  excessive  secretion  of 
saliva. 

In  aphthous  stomatitis,   distinct  grayish- 


158     Stomatitis,  or  Sore  Mouth 

white  plaques  will  he  noticed  on  the  inner 
side  of  the  cheek  and  under  surface  of  the 
tongue,  vaiying  in  size  from  a  pin-head  to 
a  split  pea. 

Ulcerative  stomatitis  is  the  most  serious 
disease  of  the  three.  It  may  occur  during 
serious  illness,  but  in  most  instances  it  occurs 
independently.  There  is  a  general  con- 
gestion of  the  mucous  membrane  with  the 
secretion  of  a  great  deal  of  saliva.  Its  dis- 
tinguishing point,  however,  is  the  line  of 
ulceration  which  forms  on  the  border  of  the 
gum  at  its  junction  with  the  teeth.  The 
ulceration  may  be  so  severe  as  to  cause  a 
loosening  and  falling  out  of  the  teeth.  The 
breath  is  often  very  foul,  and  the  gums  bleed 
at  the  slightest  touch. 

Lack  of  cleanliness  plays  a  large  part  in 
causing  sore  mouth.  Unclean  feeding  appa- 
ratus, the  use  of  the  "pacifier,"  and  the 
custom  of  allowing  a  baby  to  put  into  its 
mouth  everything  within  reach  account  for 
a  majority  of  the  cases. 

The  symptoms  are  fever,  loss  of  appetite, 
and  evidences  of  much  discomfort  when  the 
child  attempts  to  eat.  In  many  cases  of 
the  ulcerative  form  there  are  high  fever  and 


Taking  Cold  159 

greater   prostration   than   one   would   think 
possible. 

The  prevention  and  treatment  are  the 
same — cleanliness.  The  sore  mouth  should 
be  washed  with  a  saturated  solution  of  boric 
acid  after  each  feeding,  using  absorbent 
cotton,  which  is  wrapped  around  the  index 
finger.  The  cotton  is  saturated  with  the 
solution  and  gently  brought  into  contact 
with  the  diseased  surface.  Force  must  not 
be  used  in  these  cases,  as  more  damage  than 
benefit  will  result  if  the  tissues  are  lacerated. 
In  the  ulccrative  form  internal  treatment  is 
required  in  addition  to  the  local  means  sug- 
gested. Every  case  of  ulcerative  stomatitis 
should  be  seen,  at  least  once,  by  a  physician. 


By  "taking  cold"  we  understand  that 
through  the  influence  of  cold  upon  some 
portion  of  the  skin  an  impression  similar  in 
nature  to  that  of  shock  is  produced,  which 
attects  the  entire  body  and  manifests  itself 
most  frequently  in  the  form  of  a  congestion 
of  the  mucous  membrane  of  the  respiratory 
tract,  between  which  and  the  skin  there 


160  Taking  Cold 

seems  to  be  an  intimate  connection.  Micro- 
organisms play  an  important  role  in  the 
process.  They  are  found  in  large  numbers 
on  the  diseased  mucous  surfaces.  The 
changes  in  the  mucous  membrane  resulting 
from  the  exposure  prepare  the  parts  for 
their  growth  and  development.  The  taking 
of  cold  means  previous  exposure,  and  what 
will  constitute  a  sufficient  degree  of  exposure 
in  one  individual  may  produce  no  effect  in 
another.  According  to  my  observation,  the 
most  frequent  cause  of  colds  in  infancy  is 
the  action  of  cold  air  on  a  moist  skin.  The 
child  that  perspires  readily,  or  the  child 
that  is  made  to  perspire  by  unsuitable  cloth- 
ing, suffers  most  in  this  respsct  during  the 
cold  season.  I  look  upon  inadequate  head- 
covering  as  a  most  frequent  cause  of  diseases 
of  the  respiratory  tract  in  the  young.  Most 
infants  are  dressed  for  the  daily  outing  in  a 
warm  room,  with  the  temperature  ranging 
from  75°  to  85°.  The  child  is  wrapped  in 
ample  coats,  blankets,  and  leggings ;  he  is 
active,  throws  his  legs  and  arms  about;  the 
dressing  thus  far  requires  quite  a  period  of 
time  he  perspires  freely,  but  the  dressing 
is  not  completed.  On  the  head  is  placed 


Taking  Cold  161 

one  of  the  more  or  less  artistically  decorated 
airy  creations  which  are  sold  in  the  shops 
as  children's  caps.  They  furnish  little  pro- 
tection for  the  many  square  inches  of  the 
almost  bald  little  head.  The  child  is  taken 
out  of  doors;  a  wind  is  blowing;  the  result 
is  a  cold,  and  how  it  came  about  is  never 
understood.  He  was  supposed  to  be  dressed 
ideally  for  cold  weather.  The  idea  is  com- 
mon and  to  a  certain  degree  proper  that  a 
child's  head  should  be  kept  cool.  This 
theory,  however,  gives  rise  to  carelessness 
as  to  the  head-dress.  During  the  colder 
months  I  advise  mothers  to  make  a  skull-cap 
out  of  thin  flannel,  which  the  child  can 
wear  under  the  regular  outing  cap. 

Allowing  a  child  to  sit  on  the  floor  during 
the  winter  months  is  probably  the  next  most 
frequent  cause  of  taking  cold.  Kicking  off 
the  bedclothes  at  night  is  another  frequent 
cause.  Taking  the  child  from  a  warm  room 
through  a  cold  hall  is  not  without  danger. 
Holding  the  child  for  a  few  moments  by  an 
open  window  during  the  cold  weather  is 
often  followed  by  croup,  bronchitis,  and 
pneumonia.  The  uneven  temperature  of 
the-  living-  and  sleeping-rooms  in  many  of 


162  Taking  Cold 

our  New  York  apartments  is  a  very  frequent 
cause  of  cold.  Frequently  during  the  day  the 
temperature  will  be  between  75°  and  80°,  but 
at  night,  when  the  fires  are  banked,  it  falls  to 
55°  or  60°  or  lower.  The  child  went  to  bed 
warm  and  perspiring,  kicked  off  the  bed- 
clothes, the  temperature  in  the  room  fell,  the 
body  became  chilled,  and  the  child  took  cold. 

Among  rachitic  children  there  is  a  marked 
predisposition  to  catarrhal  affections ;  they 
acquire  laryngitis  and  bronchitis  upon  very 
slight  provocation. 

In  many  instances  colds  in  infants  are 
attributed  to  the  bath.  Among  dispensary 
mothers  this  is  often  considered  a  cause  of 
cold.  I  have  never  known  a  cold  to  be  due 
to  a  bath. 

Adults  and  "runabout"  children  with 
coughs  and  colds  should  not  come  in  contact 
with  infants.  There  is  undoubtedly  an 
element  of  contagion  in  such  cases.  It  is 
a  very  bad  practice  to  have  a  family  pocket- 
handkerchief.  The  youngest  infant  is  en- 
titled to  a  handkerchief  independent  of  the 
other  children,  and  a  handkerchief  should 
never  do  service  for  more  than  one  indi- 
vidual between  washings. 


Cough  163 

Mothers  can  do  little  without  medical  aid 
in  the  treatment  of  colds,  but  they  can  do 
much  in  preventing  them.  The  tempera- 
ture of  the  living-room  should  range  from 
70°  to  72°F.,  the  sleeping-room  from  60°  to 
66°  F.  Of  course  it  will  be  impossible  to 
keep  the  temperature  at  all  times  at  these 
figures,  but  the  closer  it  approximates  to 
them  the  safer  the  child  will  be. 

Children  must  not  be  allowed  to  sit  on  the 
floor  during  the  winter.  They  can  have 
their  playthings  on  the  bed,  on  the  sofa,  or 
in  a  clothes-basket,  which  may  be  raised  on 
two  thick  pieces  of  wood  or  a  couple  of  books. 
There  is  always  a  draught  near  the  floor. 
The  "pen"  referred  to  on  page  321,  is  the 
best  scheme  that  I  know  of  for  keeping 
children  from  the  floor. 

The  room  in  which  the  child  is  dressed 
for  an  outing  should  not  be  above  70°  F. 
Securely  pinning  bed -blankets  to  the  mat- 
tress, or,  better,  a  combination  suit  with 
"feet"  will  do  much  to  prevent  the  child 
from  taking  cold  at  night. 

COUGH 

The  most  frequent  cause  of  the  temporary 


1 64  Cough 

cough  seen  daily  in  children's  work  is  almost 
always  an  acute  inflammatory  condition  of 
the  mucous  membrane  of  the  respiratory 
tract,  involving  usually  the  fauces,  the 
larynx,  and  bronchi,  subjects  which  are 
referred  to  under  their  respective  headings. 
Chronic  cough. — Ninety-five  per  cent,  of 
the  obscure  coughs  are  due  to  adenoid  vege- 
tations in  the  naso-pharyngeal  vault.  In- 
cipient tuberculous  infiltration  in  any  portion 
of  the  lungs  or  pleura  may  produce  the  per- 
sistent cough.  Thorough  physical  exami- 
nations and  careful  observation  of  the  case 
for  a  few  days  will  make  a  diagnosis  possible. 
Whooping-cough  without  the  whoop  or 
vomiting  may  cause  a  persistent  cough.  It 
runs  its  course  and  subsides  in  from  four  to 
eight  weeks.  A  diagnosis  of  such  mild  cases 
of  whooping-cough  is  possible  only  when 
there  is  a  history  of  exposure  to  the  disease. 
I  have  had  occasion  to  examine  and  treat 
many  children  who  were  brought  to  me 
because  of  a  "cough"  which  had  not  been 
controlled  by  the  measures  employed.  While 
we  hear  much  of  the  cough  of  teething,  the 
"stomach  cough,"  the  "nervous  cough," 
and  the  "habit  cough,"  it  has  never  been 


Cough  165 

my  lot  to  see  a  case  in  which  the  cough  was 
not  connected  in  some  way  with  the  respira- 
tory tract.  Thorough  examination  of  these 
cases,  perhaps  repeated  examinations,  will 
be  required  before  the  site  of  the  trouble  is 
definitely  located,  when  it  will  almost  in- 
variably be  found  somewhere  in  the  respira- 
tory tract.  The  stomach  cough,  the  nervous 
cough,  and  the  teething  cough  formerly  stood 
for  the  persistent  cough  which  could  not  be 
accounted  for  by  physical  examination  of 
the  chest  or  by  mere  inspection  of  the  throat. 
They  are  frequently  referred  to  by  the  older 
writers.  An  elongated  uvula,  to  which  these 
obscure  coughs  have  also  been  attributed,  is 
very  rarely  a  cause.  The  history  is  usually 
only  that  of  a  persistent  cough.  It  may  be 
irritating  in  character,  keeping  the  child 
awake  at  night,  or  it  may  be  paroxysmal, 
the  attacks  being  more  severe  when  the  child 
is  lying  down.  Many  times  the  paroxysms 
are  so  severe,  being  particularly  worse  at 
night,  that  whooping-cough  is  suspected  be- 
cause of  the  absence  of  chest  signs. 

An  immense  majority  of  these  obscure 
coughs  in  children  are  due  to  adenoid  vegeta- 
tions with  or  without  enlarged  tonsils.  A  child 


1 66  Cough 

with  such  a  cough  may  have  the  typical  ade- 
noid face,  mouth -breathing,  and  other  signs 
referred  to  (see  Adenoids,  page  137),  or  these 
symptoms  may  be  entirely  absent.  It  is 
the  latter  type  of  case  that  is  particularly 
puzzling  and  apt  to  be  overlooked.  On 
account  of  the  absence  of  mouth -breathing 
and  other  symptoms  of  nasal  obstruction, 
the  possibility  of  adenoid  vegetations  has 
been  ignored.  In  these  cases  careful  inquiry 
will  usually  elicit  the  history  of  frequent 
colds,  or  what  is  styled  "catarrh,"  as  there 
is  more  or  less  serous  discharge  from  the 
nose,  or  the  child  is  said  to  "take  cold  in 
the  head  easily."  Digital  examination  of  the 
naso-pharyngeal  vault  will  reveal  a  fringe 
of  soft  adenoid  growth  at  the  upper  portion 
of  the  posterior  pharyngeal  wall,  not  large 
enough  to  produce  obstruction,  but  actively 
secreting.  This  secretion,  if  not  profuse, 
is  partially  evaporated  in  the  nostrils,  or  if 
profuse,  is  discharged  from  the  nostrils  or 
passes  backward  over  the  posterior  pharyn- 
geal wall,  thus  provoking  cough,  when  the 
child  is  up  and  about.  When  the  child 
rests  on  his  back,  the  secretion  naturally 
flows  over  the  posterior  pharyngeal  wall, 


Cough  167 

and  a  cough  is  the  result.  Time  and  again 
I  have  relieved  the  most  obstinate  cough 
by  curetting  and  removing  this  sponge-like 
tissue.  In  one  patient,  a  boy  two  years  of 
age,  who  had  been  coughing  hard  for  ten  days 
with  paroxysms  and  vomiting,  a  diagnosis 
of  whooping-cough  had  been  made  by  a 
member  of  the  family  who  had  seen  many 
cases  of  whooping-cough,  and  also  by  myself. 
Adenoids  were  found  to  be  present  in  a  slight 
degree.  Their  removal  was  advised,  with 
the  idea  of  making  the  coughing  attacks  less 
severe,  when,  greatly  to  our  surprise,  the 
coughing  ceased  at  once,  not  a  paroxysm 
occurring  after  the  growth  was  removed. 
The  cough  was  due  to  the  adenoid  vegeta- 
tions and  not  to  whooping-cough. 

Tracheitis  (inflammation  of  the  wind- 
pipe) will  produce  a  cough,  severe  and  in- 
tractable, with  no  signs  in  the  chest.  In 
these  cases,  however,  the  cough  is  usually 
sudden  in  its  development.  It  is  often 
accompanied  by  slight  fever,  and  if  the  child 
is  old  enough  he  will  aid  us  by  referring  to 
the  sense  of  discomfort  and  tightness  which 
exists  over  the  tipper  portion  of  the  chest. 
Sometimes  the  sensation  will  be  described 


i68  Tonsillitis 

as  a  burning,  which  is  located  directly  over 
the  trachea. 

TONSILLITIS 

Tonsillitis,  or  inflammation  of  the  tonsils, 
is  a  very  common  ailment  among  children 
during  the  colder  months.  It  usually  fol- 
lows exposure.  The  onset  is  generally 
sudden,  with  high  fever, — 103°  to  105°  P., — 
pain,  swelling,  headache,  and  general  mus- 
cular soreness.  Inspection  of  the  throat 
will  show  the  tonsils  to  be  swollen  and  in- 
flamed. The  entire  throat  generally  has 
a  congested  appearance.  No  other  changes 
may  be  noticed.  In  the  majority  of  cases, 
however,  the  tonsils  will  be  found  studded 
with  small  white  dots  of  a  cheesy  material. 
If  the  case  is  seen  two  or  three  days  after 
the  beginning  of  the  illness  the  dots  may 
have  coalesced,  forming  large  yellowish 
patches  which  so  closely  resemble  the  appear- 
ance of  the  throat  in  diphtheria,  that  it  may 
be  impossible  for  the  physician  without  the 
aid  of  a  microscope  to  differentiate  between 
the  two  diseases.  An  attack  of  tonsillitis 
runs  its  course  in  from  two  to  five  days. 


Cold  in  the  Head 


169 


Cold  applications,  cold  compresses  (see  cut) 
to  the  throat,  and  cold  spongings  of  the 


FIG.    9.      COLD   COMPRESS 

body  afford  the  patient  much  relief.  A  dose 
of  castor-oil  given  at  the  first  symptom  of 
the  disorder  will  always  be  of  value. 

COLD  IN  THE  HEAD  (CORYZA) 

A  cold  in  the  head  is  a  very  frequent 
occurrence  in  the  young,  and  while  not 
serious  if  the  trouble  limits  itself  to  the 
mucous  membrane  of  the  nose,  it  is,  never- 


1 70  Cold  in  the  Head 

theless,  a  source  of  much  annoyance  to 
both  mother  and  child.  The  mucous  mem- 
brane of  the  nasal  passages  is  congested 
and  swollen.  The  nostrils  of  infants  in 
health  are  very  narrow,  so  that  a  slight 
congestion  will  greatly  interfere  with  the 
breathing. 

The  first  sign  to  be  noticed  is  that  when 
the  child  is  nursing  he  is  unable  to  breathe 
easily  through  the  nose,  and  frequent  rests 
are  necessary.  Sleep,  for  this  reason,  is  also 
interfered  with.  The  baby  sneezes  more 
than  usual  and  there  is  a  watery  discharge 
from  the  nose  with  usually  a  degree  or  two 
of  fever.  With  the  onset  of  the  first  symp- 
toms, one  teaspoon ful  of  castor-oil  will  be 
of  service.  A  few  drops  of  melted  vaseline 
or  liquid  alboline  may  be  dropped  into  the 
nostrils  every  two  hours. 

The  danger  from  a  so-called  "cold  in  the 
head  "  rests  in  the  fact  that  the  inflammation 
does  not  always  limit  itself  to  these  parts. 
It  is  very  liable  to  extend  to  other  portions 
of  the  respiratory  tract,  terminating  some- 
times, even  if  properly  treated,  in  bronchitis 
or  broncho-pneumonia. 


Bronchitis  171 

BRONCHITIS 

Bronchitis  may  occur  as  a  primary  illness, 
or  it  may  follow  a  cold  in  the  head,  laryn- 
gitis, or  any  inflammatory  condition  of  the 
respiratory  tract.  It  often  occurs  as  a  com- 
plication of  other  diseases.  There  is  almost 
always  more  or  less  bronchitis  with  measles. 
In  bronchitis  we  have  a  serious  illness  not 
necessarily  serious  in  itself  but  mainly  so 
because  of  the  frequency  with  which  it  leads 
to  catarrhal  pneumonia.  Bronchitis  in  a 
delicate  child  requires  but  a  little  bad  man- 
agement or  neglect  and  pneumonia  will 
surely  develop. 

The  reason  why  bronchitis  is  a  dangerous 
illness  in  a  young  child  is  because  of  the  lack 
of  development  of  the  parts  which  form  the 
chest  walls.  The  ribs  arc  soft  and  the  mus- 
cles weak.  The  bronchial  tubes  collapse 
readily.  In  an  older  child  the  bronchial 
secretions  are  coughed  into  the  mouth  and 
swallowed  or  expectorated.  The  young 
infant  cannot  expectorate.  When  the  secre- 
tion is  viscid  and  thick,  the  weak  chest-wall 
fails  to  furnish  the  power  required  to  expel 
it  and  instead  it  is  drawn  deeper  into  the 


172  Bronchitis 

lungs,  the  smaller  tubes  become  clogged 
with  mucus,  the  air  vesicles  collapse,  bac- 
teria multiply  rapidly  in  the  confined  secre- 
tions, and  pneumonia  results. 

Bronchitis  is  indicated  by  coughing  and 
wheezing,  and  what  the  mother  often  calls 
"a  drawing  of  the  chest."  In  many  cases 
fever  is  present  in  a  marked  degree.  The 
severity  of  the  cough  and  the  other  symp- 
toms depend  entirely  upon  the  severity  of 
the  lesions.  In  many  cases,  if  seen  early 
the  disease  will  respond  to  treatment  in  a 
day  or  two.  A  generous  counter-irritation 
of  the  chest  with  one  part  of  turpentine  and 
three  parts  of  camphorated  oil  is  a  useful 
measure,  the  applications  to  be  made  twice 
a  day — morning  and  evening.  What  is 
better,  however,  is  the  use  of  the  mustard 
plaster,  made  by  mixing  one  part  of  mustard 
with  three  parts  of  flour,  sufficient  warm 
water  being  added  to  make  a  paste,  which 
may  be  spread  on  cheese-cloth  or  thin  muslin . 
It  should  be  large  enough  to  encircle  the 
chest,  fitting  the  child  like  a  jersey.  This 
is  covered  with  another  piece  of  similar 
material  and  the  plaster  is  complete.  It 
should  be  wrapped  around  the  chest  and 


Croup  173 

allowed  to  remain  from  ten  to  fifteen  minutes 
— until  the  skin  is  thoroughly  reddened. 

Proprietary  cough  mixtures  and  home 
remedies  should  never  be  relied  upon  for 
the  treatment  of  bronchitis  in  children. 

CROUP 

CATARRHAL   CROUP;    DIPHTHERITIC    CROUP 

There  are  two  varieties  of  croup,  catarrhal 
and  diphtheritic:  catarrhal  croup  is  a  catarrhal 
inflammation  of  the  larynx,  and  diphtheritic 
croup  a  membranous  inflammation  of  the 
larynx. 

Catarrhal  croup  may  begin  in  two  ways. 
The  child  will  suffer  from  snuffles,  indicating 
a  simple  cold  in  the  head,  which  is  followed 
by  a  slight  fever  and  a  mild  cough.  The 
cough  rapidly  becomes  worse  and  is  hoarse 
and  barking  in  character,  becoming  more 
severe  toward  evening.  As  a  rule,  the  fever 
is  not  high.  In  the  evening  of  the  second 
or  third  day  of  the  illness,  sometimes  the 
first  day,  signs  of  obstruction  to  the  breath- 
ing become  apparent.  The  inspiration  is 
labored  and  accompanied  by  a  croaking 


174  Croup 

sound.  The  child  cannot  speak  above  a 
whisper. 

Probably  not  over  half  of  the  cases  show 
this  gradual  development.  In  many  the  on- 
set is  sudden :  the  child  goes  to  bed  as  well  as 
usual;  after  a  quiet  sleep  of  a  few  hours  he 
awakes  suddenly,  sits  up  in  bed,  and  with 
high-pitched  cough,  straining  for  breath,  he 
startles  the  household. 

Membranous  or  diphtheritic  croup  is  much 
the  more  dangerous  affection,  but  to  the 
mother  there  is  no  means  of  distinguishing 
between  the  two  forms,  unless  the  child  has 
diphtheria  and  the  croup  follows.  The  two 
forms  may  appear  in  identically  the  same 
way,  although  the  onset  of  the  diphtheritic 
croup  is  usually  more  gradual. 

In  case  of  a  severe  cough  or  a  sharp  attack 
of  croup  in  one  of  the  children,  the  mother 
or  nurse  in  charge  has  three  duties  to  per- 
form: send  for  the  doctor,  isolate  the  child, 
and  give  him  a  tcaspoonful  of  the  syrup  of 
ipecac,  which  may  be  repeated  in  fifteen 
minutes  if  there  is  no  vomiting.  Every  case 
of  croup  should  be  quarantined  until  the 
nature  of  the  trouble  is  determined.  If  it 
is  catarrhal,  no  harm  will  be  done  by  the 


Croup  175 

isolation.  If  it  is  diphtheritic,  the  lives  of 
other  members  of  the  household  may  be 
saved  by  the  precaution.  If  a  croup-kettle 


FIG.     10.       THK    HOLT    CKOUI'-KETTLE 

is  at  hand  (see  cut  10),  it  should  be  brought 
into  use  after  making  a  tent  by  covering  or 
draping  the  crib  \vith  a  sheet  (sec  cut  11). 
One  teaspoonful  of  tincture1  of  benzoin  is 


176 


Croup 


added  to  one  quart  of  water  and  placed  in 
the  kettle,  which  is  heated  by  the  alcohol 


FIG.    II.       CRIB    PREPARK.n    FOR    STEAM    INHALATION 

lamp  attachment.  A  cold  compn_ss(pagc  169) 
applied  to  the  throat  is  often  beneficial  also. 


Pneumonia  177 

It  should  be  thoroughly  wrung  out,  covered 
with  some  dry  material,  and  changed  every 
twenty  minutes.  The  child  should  receive 
a  laxative  as  early  as  possible  in  the  attack. 

PNEUMONIA 

Pneumonia,  sometimes  referred  to  as  in- 
flammation of  the  lungs,  or  lung  fever, 
occurs  very  frequently  in  infants  and  young 
children.  It  may  appear  as  an  independent 
affection  or  as  a  complication  of  other  dis- 
eases. There  are  two  varieties  which  are 
commonly  met  with  in  the  young:  lobar 
pneumonia,  which  corresponds  closely  to  the 
adult  type,  and  broncho-pneumonia,  or,  as 
it  is  sometimes  called,  catarrhal  pneumonia. 

Lobar  pneumonia  usually  results  from 
exposure — a  sudden  chill  of  some  part  of  the 
surface  of  the  body. 

Broncho -pneumonia  is  usually  the  outcome 
of  bronchitis  or  what  is  known  as  "a  common 
cold." 

The  latter  is  most  frequently  seen  in  chil- 
dren and  is  usually  the  variety  which  occurs 
as  a  complication  of  other  diseases.  The 
mode  of  onset  of  the  two  types  varies.  With 


178  Pneumonia 

lobar  pneumonia  the  onset  is  sudden  there 
may  be  a  chill  or  a  convulsion.  Sometimes 
vomiting  ushers  in  an  attack.  The  fever 
rises  rapidly  to  103°  or  105°  F.  The  face 
is  flushed  and  wears  an  anxious  expression; 
the  breathing  is  rapid,  the  respirations  being 
from  40  to  60  a  minute,  the  expiration  being 
accompanied  by  a  peculiar,  partially  sup- 
pressed sigh.  The  child  is  very  restless, 
often  delirious,  or  there  may  be  stupor,  with 
symptoms  pointing  to  a  complicating  men- 
ingitis. All  the  symptoms  disappear  with 
the  advent  of  the  crisis,  when  the  fever  sud- 
denly abates  and  fails  to  rise  again.  The 
crisis  may  be  expected  any  time  between 
the  third  and  eleventh  day  of  the  recovery 
cases.  In  the  majority  of  my  cases  it  has 
occurred  from  the  fifth  to  the  seventh  day, 
in  a  few  not  until  the  ninth  day,  and  in  two 
it  did  not  occur  until  the  eleventh  day,  and 
in  one  on  the  fourteenth  day. 

The  prognosis  of  lobar  pneumonia  in 
children  is  good.  A  very  small  percentage 
fail  to  recover.  A  patient  of  mine,  a  three  - 
year-old  boy,  passed  through  two  distinct 
attacks  in  a  single  winter,  the  second  after 
an  interval  of  ten  weeks. 


Pneumonia  179 

In  catarrhal  or  broncho -pneumonia  the 
story  is  different.  There  may  be  a  pneu- 
monia at  the  commencement  of  the  illness, 
but  according  to  my  observation,  which 
covers  several  hundred  cases,  the  majority 
begin  with  symptoms  of  a  common  cold  or 
bronchitis,  the  lungs  becoming  involved 
gradually.  In  other  words,  the  onset  is 
gradual,  not  sudden,  whether  it  occurs  inde- 
pendently or  as  a  complication  of  some  other 
disease.  There  are  cough,  often  distressing, 
moderate  fever,  rapid  breathing,  loss  of 
appetite,  and,  later,  emaciation.  Broncho- 
pneumonia  in  children  is  an  affection  of 
extreme  gravity.  There  is  no  well-defined 
crisis  as  in  lobar  pneumonia.  The  disease 
may  last  a  week  or  two  weeks,  or  it  may 
continue  for  months.  In  one  of  my  cases, - 
a  child  eighteen  months  of  age, — the  disease 
continued  three  months  before  the  low  fever 
abated  and  the  lungs  were  clear.  The  re- 
covery cases  often  require  from  three  to  four 
weeks  before  the  lungs  may  be  considered 
normal. 

The  sick-room  of  a  patient  ill  with  pneu- 
monia should  be  large,  with  one  window 
open  at  least  four  inches  fn  >ni  the  top  on  the 


180     The  Contagious  Diseases 

coldest  days.  The  temperature  of  the  room 
should  not  be  below  55°  F.  or  above  65°  F. 
The  child  should  be  put  on  a  reduced  diet 
of  animal  broths,  thin  gruels,  and  diluted 
milk. 

Prevention  resolves  itself  into  proper  care 
of  the  child,  proper  clothing,  avoidance  of 
unnecessary  exposure,  and  an  appreciation 
of  the  fact  that  with  a  child  it  is  almost  as 
necessary  to  call  a  physician  for  a  common 
cold  or  bronchitis  as  it  is  for  scarlet  fever  or 
diphtheria. 

THE  CONTAGIOUS  DISEASES 

A  contagious  disease  is  one  due  to  a  spe- 
cific poison  which  under  favoring  conditions 
possesses  the  power  of  reproducing  itself  in 
the  person  of  another.  The  poison  of  the 
disease,  the  contagium,  may  be  transmitted 
either  directly  by  contact  with  an  individual 
suffering  from  the  disease,  or  indirectly  by 
means  of  some  person  or  object,  such  as  the 
clothing  or  hands  of  the  attendants,  which 
have  been  in  contact  with  the  one  infected. 
According  to  my  observation,  personal  con- 
tact with  the  infected  is  required  in  a  large 


The  Contagious  Diseases      181 

proportion  of  cases.  Measles  and  whooping- 
cough  are  unquestionably  the  most  con- 
tagious diseases  of  this  type,  requiring  for 
their  transmission  only  a  very  slight  ex- 
posure. German  measles  and  chicken-pox 
are  next  in  order  of  communicability,  while 
scarlet  fever  is  less  contagious  than  any  of 
those  mentioned — a  close  contact  and  a 
fairly  long  exposure  being  usually  required. 
Clothing  may  be  infected  by  the  contagium 
of  scarlet  fever  and  diphtheria,  the  poison 
remaining  inactive  for  a  long  time. 

A  little  girl,  four  years  of  age,  who  lived 
in  one  of  the  Hudson  Valley  villages,  con- 
tracted scarlet  fever  while  on  a  visit  to  a 
neighboring  town;  the  case  was  a  severe  one 
and  the  child  died.  A  coat  which  she  had 
worn  when  stricken  with  the  disease  was 
carefully  laid  away  in  a  bureau  drawer. 
Twelve  months  later  the  mother  decided  to 
give  the  coat  to  a  neighbor's  child.  It  was 
removed  from  the  bureau,  which  had  re- 
mained unopened,  and  placed  on  the  little 
one.  In  five  days  she  was  attacked  with 
scarlet  fever.  These  were  the  only  two 
cases  that  had  occurred  in  the  village.  The 
second  child  had  not  been  awav  from  home 


1 82  Scarlet  Fever 

and  the  jacket  was  the  only  possible  means 
of  infection. 

Diphtheria  through  personal  contact  alone 
is  probably  the  least  contagious  of  any  of 
the  diseases  belonging  in  this  group.  Its 
virulence,  however,  renders  every  preventive 
measure  imperative. 

Smallpox,  thanks  to  compulsory  vacci- 
nation, is  seen  so  rarely  that  it  need  not  be 
considered  here. 

SCARLET  FEVER 

Scarlet  fever  is  one  of  the  most  important 
of  the  contagious  diseases,  and  whether  a 
case  is  mild  or  severe  it  requires  the  greatest 
watchfulness  on  the  part  of  both  physician 
and  nurse,  nor  can  their  vigilance  be  safely 
relaxed  until  the  patient  has  been  apparently 
well  for  at  least  five  or  six  weeks.  The 
period  of  incubation  varies  considerably. 
In  the  majority  of  cases  the  first  sign  of 
trouble  is  noticed  from  three  to  five  days 
after  exposure.  In  one  of  my  cases  twelve 
days  elapsed  between  the  time  of  exposure 
and  the  initial  symptom,  if,  however,  nine 
days  pass  without  evidence  of  illness,  the 


Scarlet  Fever  183 

child  may  ordinarily  be  considered  safe, 
but  the  exposed  should  not  come  in  contact 
with  other  children  until  at  least  fourteen 
days  have  elapsed.  Infection  usually  takes 
place  from  direct  contact,  although  the 
contagium,  the  nature  of  which  is  unknown, 
may  be  carried  by  means  of  clothing,  toys, 
books,  or  a  third  person.  Doctors  who  do 
not  wear  gowns  while  attending  scarlet  fever 
patients,  and  are  careless  about  washing 
their  hands  after  examining  such  cases, 
may  themselves  carry  the  disease.  One 
attack  usually  protects  against  a  second, 
although  cases  are  on  record  of  the  occur- 
rence of  two  or  three  attacks  in  the  same 
individual. 

The  onset  of  scarlet  fever  is  sudden,  often 
with  vomiting,  occasionally  with  a  convul- 
sion, always  with  fever  and  sore  throat. 
The  fever  is  usually  high,  103°  to  105°  P., 
though  it  may  be  low, — 101°  to  102°  F. 
When  the  latter  is  the  case  the  course  of 
the  disease  will  probably  be  mild.  Whether 
the  fever  is  high  or  low,  the  deeply  red,  con- 
gested throat  is  usually  present.  From 
twenty-four  to  thirty-six  hours  after  the 
initial  symptom  the  rash  makes  its  appear- 


184  Scarlet  Fever 

ance.  In  many  mild  cases  it  will  be  the 
first  symptom  noticed.  The  character  of 
the  rash,  its  intensity,  and  the  height  of  the 
fever  indicate  fairly  well  the  severity  of  the 
attack.  The  chest  and  abdomen  are  usually 
the  site  of  the  first  appearance  of  the  rash. 
It  is  composed  of  minute  red  dots  so  closely 
set  together  as  to  give  the  skin  a  deep  scarlet 
color.  The  extent  of  the  rash  varies  greatly ; 
in  some  cases  it  covers  the  entire  body  and 
lasts  from  six  to  seven  days.  In  others,  it 
is  much  less  distinct,  covering  only  limited 
areas,  and  may  last  for  only  a  few  hours. 
In  one  of  my  cases  it  was  visible  for  only  six 
hours  after  it  was  first  noticed;  while  in  all 
other  respects  the  case  was  one  of  typical 
scarlet  fever.  Ordinarily  the  rash  begins 
to  fade  about  the  fourth  or  fifth  day  and  is 
followed  by  the  desquamation  period.  This 
is  also  variable  in  extent;  there  may  be  but 
a  light  peeling  of  the  palms  of  the  hands, 
and  of  the  finger-tips  about  the  nails,  or  it 
may  be  most  profuse,  the  epidermis  peeling 
off  in  large  flakes  from  the  entire  surface  of 
the  body.  From  two  to  three  weeks  are 
required  to  complete  this  process. 

Complications  are  a  common   occurrence 


German  Measles  185 

in  scarlet  fever,  and  it  is  the  complications 
which  are  usually  the  cause  of  death  in  the 
fatal  cases.  The  kidneys,  heart,  lungs,  and 
ears  are  particularly  liable  to  serious  in- 
volvement. 

An  error  frequently  made  is  to  allow  the 
child  convalescent  from  scarlet  fever  to  be 
out  of  bed  too  early.  He  should  never  be 
allowed  to  run  about  before  four,  or,  better 
still,  five  or  six  weeks  have  elapsed.  The 
peeling  may  be  hastened,  the  disease  cur- 
tailed, and  the  danger  of  spreading  lessened 
by  a  daily  sponge  bath  followed  by  an  inunc- 
tion with  sweet  oil  or  vaseline. 

GERMAN  MEASLES 

German  measles  is  a  contagious  disease 
of  a  very  mild  type,  ordinarily  the  rash  being 
the  first  sign  of  illness.  This  may  have  been 
preceded,  however,  by  a  slight  chilliness  and 
soreness  of  the  muscles.  The  eruption  is  of 
a  reddish-brown  color  and  appears  more 
extensively  on  the  face  and  chest  than  on 
other  parts  of  the  body.  The  spots  vary 
in  size  from  a  pin-head  to  a  flaxsecd.  In 
well-developed  cases  the  rash  may  cover 


1 86  Mumps 

the  entire  surface  of  the  body.  The  tem- 
perature is  usually  low  and  lasts  but  a  day 
or  two.  I  have  never  seen  it  above  102°  P. 
There  is  little  or  no  inflammation  of  the 
eyes,  nose,  or  throat,  in  marked  contradis- 
tinction to  measles.  There  is  no  cough  and 
the  child  suffers  very  little  inconvenience. 
The  glands  behind  the  ear  and  at  the  sides 
of  the  neck  are  almost  always  enlarged  and 
sensitive, — this  with  the  fever  and  the  rash 
comprising  the  chief  symptoms  of  the  disease. 
The  duration  of  the  rash  varies  from  one  to 
three  days.  Usually  at  the  end  of  forty- 
eight  hours  the  skin  will  be  found  clear. 

My  treatment  is:  two  or  three  days  in  bed 
and  a  light  diet. 

MUMPS 

Mumps  is  an  inflammation  of  one  or  both 
parotid  glands.  One  attack  usually  pro- 
tects against  another.  The  disease  is  usu- 
ally acquired  by  contact  with  the  infected. 
It  is  extremely  doubtful  that  it  can  be  car- 
ried by  a  third  party.  The  period  of  time 
required  for  the  development  of  the  disease 
after  exposure  varies  considerably;  but  from 


Mumps  187 

two  to  three  weeks  may  be  considered  the 
period  of  incubation. 

The  first  symptoms  are  similar  to  those 
of  the  other  contagious  diseases.  There 
are  loss  of  appetite,  headache,  languor,  and 
slight  fever.  In  addition  to  these  general 
symptoms,  the  child  complains  of  pain  upon 
swallowing,  or  upon  moving  the  jaw.  Vine- 
gar or  any  acid  substance  taken  into  the 
mouth  causes  considerable  pain  or  discomfort 
behind  the  jaws  and  under  the  ears.  In  a 
few  hours  there  will  be  noticed  a  swelling 
of  the  parotid  gland  in  front  of  and  under 
the  ear.  Both  sides  rarely  begin  to  swell 
at  the  same  time;  the  swelling  of  one  gland 
usually  precedes  that  of  the  other  by  a 
couple  of  days.  It  increases  gradually  for 
two  or  three  days  until  it  reaches  its  height, 
when  it  begins  to  subside  slowly,  reaching 
the  normal  in  eight  or  ten  days  from  its 
beginning.  The  temperature  during  the  at- 
tack ranges  from  100°  to  103°  P. 

The  complications  of  mumps  in  children 
are  few,  and  the  disease  cannot  be  regarded 
as  dangerous.  Acute  Bright's  disease  fol- 
lowed an  attack  of  mumps  in  one  of  my 
patients.  Swelling  of  the  testieles  is  a 


1 88  Whooping-Cough 

comparatively  rare  occurrence.  Ear  disease 
is  an  infrequent  but  possible  complication. 
Multiple  abscesses  may  develop  in  the  parotid 
gland,  but  this  is  also  a  very  rare  occurrence. 
Other  acute  glandular  swellings  at  the  angle 
of  the  jaw  are  often  mistaken  for  mumps; 
in  murnps,  however,  the  swelling  is  always 
in  front  of,  under,  and  behind  the  ear.  A 
simple  glandular  enlargement  may  be  located 
at  any  point  under  or  behind  the  jaw. 

A  child  with  mumps  should  be  kept  in  bed 
until  the  swelling  has  subsided,  and  given 
plain,  easily  digested  food.  The  mouth 
should  be  rinsed  after  each  meal  with  a 
saturated  solution  of  boracic  acid.  For  the 
pain  and  discomfort  caused  by  the  swelling, 
hot  applications  answer  best.  Flannel  wrung 
out  of  very  hot  water  and  bound  upon  the 
parts  always  furnishes  some  relief.  The 
flannel  should  be  kept  hot  by  repeatedly 
dipping  it  into  hot  water.  The  heat  will 
be  retained  better  if  the  flannel  is  covered 
with  oiled-silk. 

WHOOPING-COUGH 
In  whooping-cough  we  have  one  of  the  most 


Whooping-Cough  189 

dangerous  diseases  of  childhood,  dangerous 
in  the  extreme  for  the  very  young,  the  deli- 
cate, and  the  rachitic.  In  itself  it  is  seldom 
directly  fatal,  but  the  frequent  complica- 
tions of  catarrhal  pneumonia  in  winter 
and  intestinal  diseases  in  summer  make  it 
indirectly  responsible  for  the  loss  of  many 
lives. 

The  period  of  incubation  ranges  from 
seven  to  fourteen  days.  At  the  commence- 
ment of  the  disease  the  cough  is  not  severe 
and  often  cannot  be  distinguished  from  that 
of  bronchitis  or  a  common  cold.  The  cough, 
however,  does  not  respond  to  treatment 
for  coughs  and  colds;  it  increases  in  severity, 
becoming  paroxysmal  in  character  and  worse 
at  night.  During  the  paroxysms  the  eyes 
water,  the  face  becomes  red  and  congested, 
the  seizure  often  ending  in  vomiting.  The 
characteristic  whoop  usually  develops  after 
ten  clays  or  two  weeks.  In  the  mild  cases 
there  may  be  but  two  or  three  paroxysms 
daily ;  in  the  severe  cases  there  are  usually 
from  twenty  to  thirty  in  twenty-four  hours. 
I  have  seen  a  few  cases  in  which  the  disease 
was  so  mild  that  the  whoop  never  appeared, 
while  others  whooped  but  once  during  an 


190  Whoopi  rig-Cough 

entire  attack.  The  disease  varies  not  only 
in  its  severity,  but  in  its  duration  as  well. 
Occasionally  cases  are  seen  which  run  the 
entire  course  in  four  weeks;  unfortunately, 
they  are  rare.  As  a  rule,  from  eight  to  ten 
weeks  elapse  before  the  child  may  be  con- 
sidered well. 

As  long  as  the  child  continues  to  whoop, 
or  the  cough  is  distinctly  paroxysmal,  it  is 
not  safe  for  him  to  come  in  contact  with 
the  unprotected.  The  active  stage,  during 
which  the  paroxysms  are  frequent  and 
severe,  rarely  lasts  longer  than  two  or  three 
weeks.  Sometimes  after  a  period  of  three 
or  four  months  without  whooping,  the  child 
takes  cold,  develops  a  cough  paroxysmal  in 
character,  and  the  whoop  returns;  but  this 
does  not  mean  that  there  is  a  return  of  the 
whooping-cough,  and  such  children  need 
not  be  quarantined. 

Whooping-cough  cannot  be  cured;  it  must 
run  its  course.  The  author's  observations, 
which  cover  the  management  of  over  one 
thousand  cases,  prove  that  every  ease  may 
be  ameliorated  and  its  course  perhaps  short- 
ened. The  home  treatment  demands  an 
abundance  of  fresh  air.  The  child  should 


Diphtheria  191 

spend  the  greater  part  of  every  pleasant  day 
out  of  doors  and  sleep  with  the  window  open 
an  inch  or  two  from  the  top,  regardless  of 
the  weather. 

DIPHTHERIA 

Diphtheria  is  a  disease  due  to  a  germ 
which  is  known  as  the  Klebs-Loeffler  bacillus. 
It  lodges  upon  the  mucous  membrane  of  the 
throat  or  nose,  and  there  starts  up  a  process 
known  as  diphtheria.  The  disease  is  usually 
of  slow  and  insidious  onset,  requiring  two  or 
three  days  for  its  complete  development. 
The  period  of  incubation  varies  greatly;  a 
child  may  develop  diphtheria  within  twenty- 
four  hours  after  exposure,  or  it  may  be 
delayed  a  month  or  six  weeks.  In  children 
who  have  been  exposed,  there  should  be  a 
microscopical  examination  of  the  secretion 
from  the  throat,  which  may  settle  the  ques- 
tion as  to  the  child's  liability  to  contract  the 
disease. 

The  first  symptoms  are  fever  and  rest- 
lessness, loss  of  appetite,  and  disinclination 
to  play.  The  child  may  complain  of  pain 
upon  swallowing,  and  in  many  cases,  very 


192  Diphtheria 

early  in  the  attack,  swelling  may  be  noticed 
at  the  angle  of  the  jaw.  Inspection  of  the 
throat  shows  the  characteristic  patches  of 
the  membrane.  In  some  cases  these  patches 
resemble  a  thin  layer  of  putty  spread  over 
the  parts.  Others  present  the  appearance 
of  a  very  light-yellow  paint  splashed  upon 
the  tonsils  and  adjacent  parts.  The  mem- 
brane may  be  located  in  the  nose,  throat, 
larynx,  eye, — in  fact,  any  mucous  surface 
may  become  infected;  fresh  wounds  may 
also  become  infected.  The  usual  sites,  how- 
ever, are  the  nose,  throat,  and  larynx.  The 
disease  may  be  transmitted  by  direct  con- 
tact, by  means  of  contaminated  clothing,  toys, 
pictures,  books,  or  the  germs  may  1  >e  carried 
on  the  hands  or  clothing  of  an  attendant. 
One  attack  does  not  protect  against 
another.  There  is  evidence  that  a  certain 
degree  of  immunity  is  established,  but  it 
probably  is  not  effective  for  more  than  a 
few  months.  Diphtheria  does  not  run  a 
definite  course,  like  the  other  infectious 
diseases.  We  cannot  say  that  certain  defi- 
nite signs  will  be  present  on  certain  days. 
It  is  the  most  uncertain  and  treacherous 
disease  with  which  we  have  to  deal. 


Diphtheria  193 

The  only  treatment  of  value  other  than 
supportive  measures  is  the  use  of  antitoxin, 
which  must  be  given  early  in  the  disease- 
as  soon  as  a  diagnosis  of  diphtheria  is  made. 
In  fact,  I  believe  it  is  advisable  to  give  it 
in  all  cases  where  there  is  any  uncertainty 
as  to  whether  the  case  is  tonsillitis  or  diph- 
theria. Much  valuable  time  may  be  lost 
by  delay.  The  antitoxin  should  be  repeated 
in  from  twelve  to  twenty-four  hours  if  im- 
provement does  not  follow.  I  have  been 
obliged  in  four  cases  to  give  three  injections 
of  5000  units  each.  In  one  severe  case,  in- 
jections of  40,000  units  were  required.  In  the 
majority  of  my  cases  two  injections  of  5000 
units  each  were  required.1  No  harm  results 
from  the  use  of  antitoxin.  I  have  employed 
it  in  a  great  many  cases  and  have  lost  but 
two.  One  child  I  did  not  see  until  the  fourth 
day  of  its  illness,  which  was  too  late  for  the 
antitoxin  to  be  of  any  service.  The  general 
mortality  of  diphtheria  has  been  markedly 
reduced  through  its  use.  During  conva- 
lescence, the  child  must  not  be  allowed  to 


i94  Chickcn-Pox 

mingle  with  other  children  until  a  bacteri- 
ological examination  of  the  throat  shows  it 
to  be  free  from  diphtheritic  germs. 

The  instructions  for  the  preparation  of 
the  sick-room,  for  disinfection  and  quaran- 
tine, will  be  found  on  pages  198-201. 

CHICKEN-POX 

Chicken-pox  is  one  of  the  milder  con- 
tagious diseases.  Among  several  hundred 
cases  I  have  seen  but  two  that  were  severe 
enough  to  endanger  life. 

The  period  of  incubation  is  quite  long, — 
from  fourteen  to  twenty -one  days.  There 
is  slight  fever  at  the  onset,  rarely  high 
enough,  however,  to  be  noticed  by  the 
mother  or  nurse.  More  frequently  the  first 
sign  of  the  disease  is  the  characteristic 
eruption  which  may  appear  on  any  portion 
of  the  body,  the  scalp  sometimes  being 
particularly  involved.  The  rash  consists 
of  very  small  blisters  which  from  a  distance 
give  to  the  skin  the  appearance  of  having 
been  sprinkled  with  water.  The  fluid  soon 
disappears,  leaving  a  dark-colored  crust. 
When  the  crusts  fall,  a  small  scar  is  often 


Measles  195 

left,  which  may  remain  for  several  months. 
In  an  ordinary  case  the  skin  will  not  be  clear 
before  the  end  of  the  third  or  fourth  week. 

The  child  should  be  kept  indoors  during 
the  attack,  and  given  a  reduced  diet.  The 
itching  is  often  relieved  by  sponging  with 
a  weak  solution  of  alcohol  in  water, — four 
ounces  to  a  pint,- — followed  by  a  gentle 
application  of  vaseline. 

I  never  advise  quarantine  against  chicken- 
pox  except  to  avoid  needless  exposure  of  very 
young  or  delicate  children  in  the  family. 
The  patient  should  not  return  to  school  or 
be  allowed  to  mingle  with  other  children- — 
in  short,  is  not  to  be  considered — well  until 
the  skin  is  clear. 

MEASLES 

The  incubation  period  of  measles- — the 
time  required  between  the  exposure  and  the 
development  of  the  first  symptom — varies 
between  nine  and  twelve  days.  One  attack 
usually  protects  against  a  second.  This, 
however,  is  not  invariably  the  ease.  I  have 
a  patient,  a  young  girl,  eighteen  years  old, 
who  contracts  measles  everv  time  she  is 


196  Measles 

exposed.     She  recently  passed  through  her 
fourth  attack,  which  was  most  severe. 

The  onset  of  the  disease  closely  resembles 
that  of  a  common  cold.  The  symptoms  are 
slight  fever,  100°  to  102°  F.,  redness  of  the 
eyes  and  intolerance  of  light,  a  watery  dis- 
charge from  the  nose,  a  dry,  hard  cough, 
pain  on  swallowing,  and  loss  of  appetite. 
The  peculiar  swollen,  congested  condition  of 
the  eyes  and  face  often  makes  a  diagnosis 
possible  before  the  appearance  of  the  rash. 
This  usually  first  appears,  from  the  second 
to  the  fourth  day  of  the  illness,  upon  the  face 
and  chest.  At  first  there  are  small,  irregu- 
larly shaped  spots  said  to  resemble  fleabites. 
The  spots  coalesce,  the  rash  extends,  and 
in  one  or  two  days  the  greater  portion  of  the 
skin  is  involved.  The  rash  remains  at  its 
height  for  two  or  three  days,  when  it  begins 
to  fade,  and  in  two  or  three  days  more  the 
skin  becomes  clear.  With  the  subsidence 
of  the  rash,  desquamation  or  peeling  of  the 
skin  begins.  This  consists  in  the  shedding 
of  fine,  thin  scales.  The  fever  and  prostra- 
tion keep  pace  fairly  well  with  the  rash. 
The  fever,  which  may  range  between  102° 
and  105°  P.,  reaches  its  highest  point  with 


Measles  197 

the  complete  development  of  the  rash.  With 
the  fading  of  the  rash  the  fever  also  mod- 
erates. The  cough  in  measles  is  hard  and 
dry  in  character  and  is  often  quite  severe. 
It  must  be  remembered  that  the  congestion 
of  the  respiratory  mucous  membrane  which 
causes  the  cough  is  a  part  of  the  disease. 
The  cough  may  be  relieved,  but  it  will  not 
subside  until  the  disease  has  run  its  course. 
There  is  always  considerable  involvement 
of  the  eyes,  the  lids  being  red  and  swollen, 
with  a  free  secretion  of  watery  mucus.  In 
many  families  but  little  attention  is  paid 
to  measles — it  is  regarded  with  more  or  less 
indifference.  While,  in  most  instances,  the 
disease  may  not  be  particularly  dangerous, 
we  must  remember  that  it  is  sometimes  quite 
virulent,  and  domestic  treatment  should 
never  be  relied  upon.  There  is  always  more 
or  less  bronchitis,  which  in  young  and  deli- 
cate infants  constitutes  a  severe  complica- 
tion, leading,  as  it  often  does,  to  catarrhal 
pneumonia. 

The  eyes  should  be  washed  daily  with  a 
saturated  solution  of  boracic  acid.  Their 
sensitive  condition  requires  also  a  darkened 
room,  and  failure  to  appreciate  this  fact 


198  The  Sick-Room 

has  often  resulted  in  their  permanent  injury. 
A  darkened  room,  however,  does  not  mean 
a  room  devoid  of  ventilation;  fresh  air  for  a 
patient  with  a  contagious  disease  is  almost 
as  important  as  nourishment.  The  diet 
must  be  simple;  only  fluid  diet  should  be 
given  to  "runabouts,"  while  for  infants  the 
usual  milk  mixture  should  be  diluted  with 
boiled  water  from  one-third  to  one-half. 
The  child  should  have  a  lukewarm  sponge- 
bath  every  day,  followed  by  an  inunction 
of  vaseline,  which  not  only  relieves  the 
itching,  but  renders  the  patient  much  more 
comfortal  >le. 

Children  convalescent  from  measles  should 
not  be  allowed  to  go  to  school  or  mingle  with 
the  unprotected  until  two  weeks  after  the 
completion  of  desquamation. 

SICK-ROOM  FOR  CONTAGIOUS  DISEASES 

QUARANTINE 

A  child  ill  with  a  contagious  disease  should 
always  be  isolated,  whether  there  are  un- 
protected children  in  the  family  or  not. 
Quarantine  can  be  carric-d  out  only  when 
the  child  is  placed  in  a  room  alone  with  the 


The  Sick-Room  199 

nurse  or  mother,  and  neither  allowed  to 
leave  the  room  or  in  any  way  to  come  in 
contact  with  other  members  of  the  family. 
If  possible  the  room  should  be  on  the  top 
floor  of  the  house.  The  furniture  should  be 
of  the  simplest, — no  fancy  curtains  and  no 
upholstery.  A  perfectly  bare  floor  is  best. 
If  two  nurses  are  required,  two  isolating 
rooms  will  be  necessary,  one  to  be  used  as  a 
sleeping-room.  The  meals  should  be  carried 
on  a  tray  and  placed  upon  a  chair  outside 
the  closed  door  of  the  isolating  room.  The 
dishes  containing  the  food  are  to  be  removed 
by  the  person  isolated.  After  use,  before 
returning  the  dishes  to  the  chair  outside  the 
door,  they  should  be  placed  for  five  minutes 
in  boiling  water.  Only  wash  goods  should 
be  worn  by  the  attendants,  and  their  cloth- 
ing, with  bed  linen  when  changed,  should 
be  placed  in  boiling  water—one  ounce  of 
carbolic  aeid  to  two  gallons  of  water — before 
it  is  sent  to  the  laundry. 

\Yhen  other  members  of  the  family  are 
allowed  to  go  at  will  into  and  out  of  the 
isolating  room,  the  value  of  the  quarantine 
is  practically  lost.  If  the  illness  is  of  a 
serious  nature,  such  as  scarlet  fever  or 


200  The  Sick-Room 

diphtheria,  the  other  children  of  the  family 
should  be  sent  to  other  quarters ;  particularly 
should  this  be  done  if  the  family  occupy  an 
apartment. 

DISINFECTANT    DRUGS 

The  erroneous  views  possessed  by  many 
concerning  disinfection  often  result  in  much 
harm.  Too  many  are  satisfied  by  the  use 
of  disinfectant  solutions  and  drugs  at  the 
expense  of  cleanliness.  Any  agent  that  will 
destroy  germs  is  a  disinfectant.  Disinfec- 
tion really  means  cleanliness.  Disinfectants 
can  never  supplant  hot  water,  common 
yellow  soap,  and  a  nail-brush.  Dipping  the 
hands  into  a  solution  of  carbolic  acid  or 
bichloride  of  mercury  will  not  make  them 
clean,  much  less  sterile.  Sprinkling  either 
of  these  substances  upon  the  floor  will  not 
clean  the  iloor  or  be  of  one  particle  of  service. 
Scrubbing  the  floor  of  the  sick-room  once  a 
day,  using  hot  water,  sapolio,  and  a  stiff 
brush,  will  do  more  to  prevent  the  circu- 
lation of  the  germ-laden  dust  than  any 
disinfectant  which  can  be  used.  I  recently 
saw  a  young  mother  change  the  baby's 


Disinfection  201 

napkin,  immediately  after  which,  with  hands 
untouched  by  soap  or  water,  she  very  care- 
fully washed  out  the  baby's  mouth  with  the 
boracic  acid  solution!  The  young  mother 
was  anxious  to  do  her  full  duty  by  the  child, 
but  had  never  learned  the  rudiments  of 
disinfection. 

Disinfectant  solutions  and  drugs  are  of 
much  service  when  used  after  a  thorough 
scrubbing  with  hot  water,  soap,  and  brush,— 
never  before. 

DISINFECTION    AFTER    CONTAGIOUS 
DISEASES— FUMIGATION 

Before  being  allowed  to  resume  his  place 
in  the  family,  the  child  who  has  recovered 
from  a  contagious  disease  should  be  given 
a  tub-bath,  with  a  vigorous  scrubbing  with 
soap  and  warm  water.  The  hair  should  lie 
washed  with  a  i  to  2000  solution  of  bichlo- 
ride of  mercury,  and  the  child  dressed  in 
fresh  clothing  outside  the  sick-room. 

The  soiled  clothing  and  the  bedding  which 
can  be  washed  should  be  put  into  a  solution 
of  one  ounce-  of  carbolic  acid  to  two  gallons 
of  water.  The  vessel  should  be  covrtvd  and 


202  Fumigation 

removed  to  the  laundry  and  the  clothing 
boiled  thirty  minutes.  The  bedding  and 
such  articles  as  cannot  be  washed  should  be 
spread  over  the  furniture  in  readiness  for 
fumigation. 

The  windows  and  doors  must  be  closed 
and  sealed,  when  the  room  can  be  fumigated 
with  sulphur  or  formalin.  If  sulphur  is 
used,  three  pounds  of  roll  sulphur  are  re- 
quired by  the  New  York  Health  Department 
for  even'  thousand  cubic  feet  of  air  space. 
The  sulphur  is  placed  in  an  iron  vessel  which, 
as  a  precaution  against  fire,  should  stand 
on  a  large  piece  of  tin  or  zinc.  Alcohol  is 
poured  over  the  sulphur  and  ignited,  after 
which  the  room  should  not  be  opened  for 
twenty-four  hours.  If  the  air  in  the  room 
can  be  charged  with  a  moderate  amount 
of  vapor  from  an  open  vessel  on  a  stove  or 
radiator,  the  sulphur  disinfection  will  be 
more  complete.  Formalin  acts  as  a  much 
better  disinfectant  and  is  far  less  objec- 
tionable than  sulphur.  The  formalin  appa- 
ratus with  directions  for  its  use  can  be  rented 
at  a  moderate  price  from  most  Xew  York 
druggists. 

After  the  fumigation,  the  carpet  or  rugs, 


The  Delicate  Child  203 

mattresses  and  pillows,  are  taken  charge 
of  by  the  health  authorities  in  the  larger 
cities,  steamed,  and  returned  in  two  or  three 
days  free  of  expense  to  the  owner.  Other- 
wise such  articles  should  be  sent  to  the 
cleaner  and  the  mattresses  and  pillows 
re-covered.  The  floor  of  the  room  and  the 
woodwork  should  be  scrubbed  with  hot 
water,  brush,  and  soap.  When  dry  they 
should  be  washed  with  a  i  to  2000  solution 
of  bichloride  of  mercury.  The  furniture 
should  also  be  washed  with  the  bichloride 
solution.  If  the  walls  are  papered,  they 
should  be  wiped  with  cloths  moistened  with 
this  solution;  but  it  is  better  to  have  the 
room  re-papered.  If  the  walls  are  painted, 
they  should  be  washed  with  the  solution. 
If  the  walls  can  be  newly  papered,  painted, 
or  kalsomined,  much  greater  security  will 
be  enjoyed  by  the  future  occupant. 

THE  DELICATE  CHILD 

In  work  among  children  one  frequently 
meets  with  those  who,  while  they  cannot 
be  said  to  be  suffering  from  any  disease  or 
pathologic  condition,  yet  are  inferior  in 


204  The  Delicate  Child 

physical  development,  lack  endurance,  and 
possess  poor  resisting  powers.  They  are 
often  under  height,  always  under  weight, 
and,  in  short,  have  so  many  character- 
istics in  common  that  they  constitute  a 
class  by  themselves,  and  as  such  warrant 
our  attention. 

Normal  development. — The  average  child, 
at  the  various  periods  of  early  life,  conforms 
with  a  certain  degree  of  regularity  to  the 
mental  and  physical  development  which 
by  long  association  we  have  come  to  regard 
as  normal.  Thus  a  standard  may  be  said 
to  have  been  established,  and  it  is  up  to 
this  standard  that  we  expect  the  growing 
child  to  measure.  This  is  what  we  look 
upon  as  the  average  of  physical  and  mental 
development.  A  few  children  exceed  these 
requirements:  they  are  stronger  and  larger 
at  the  sixth  month  than  the  average  child  at 
the  ninth  month.  Again,  older  children 
at  the  fourth  or  fifth  year  are  in  every  way 
equal  to  their  normal  playmates  a  year  or 
two  older. 

Abnormal  development. — On  the  other 
hand,  there  are  children  who  are  born  with 
a  reduced  vitality,  or  who,  through  faulty 


The  Delicate  Child  205 

management,  usually  in  relation  to  feeding, 
acquire  a  reduced  vitality.  Semi-invalid 
adults  almost  invariably  beget  semi-invalid 
children.  If  the  parents  are  of  average 
health  and  of  good  habits,  and  the  debilitated 
condition  of  the  child  is  due  to  faulty  man- 
agement and  nutritional  errors,  the  result 
of  proper  dietetic  and  hygienic  management 
is  usually  prompt  and  satisfactory.  With 
the  persistently  delicate,  the  offspring  of 
physically  enfeebled  parents,  the  results  arc 
less  satisfactory,  but  improvement  is  always 
possible. 

Management. — By  proper  regulation  of 
the  habits  of  a  delicate  child,  as  regards  all 
the  details  of  his  daily  life,  a  far  better  adult 
is  produced  than  if  no  such  effort  had  been 
made.  In  other  words,  a  diet  and  general 
regime  of  life  best  adapted  to  the  individual 
in  question  will  invariably  improve  the 
physical  condition  of  that  individual.  This 
applies  to  the  strong  as  well  as  to  the  deli- 
cate, to  the  growth  and  development  of  the 
young  of  the  lower  animals  as  well  as  to  the 
offspring  of  man.  It  is  the  poorly  developed, 
delicate  child  that  we  are  particularly  to 
consider — the  undersized,  frail,  small-boned, 


206  The  Delicate  Child 

under- weight  child,  whose  appetite  is  per- 
sistently poor  or  capricious,  who  sleeps 
poorly,  tires  easily,  is  usually  constipated, 
who  is  subject  to  catarrhal  conditions  of 
the  respiratory  tract,  and  whose  powers 
of  resistance  generally  are  diminished.  In 
not  every  delicate  child  will  all  these  symp- 
toms be  found.  Under- weight  and  one  or 
more  of  the  other  conditions  referred  to  will 
usually  be  present. 

On  assuming  the  management  of  one  of 
these  children  it  is  absolutely  necessary  to 
make  a  thorough  examination,  followed  in 
some  instances  by  a  few  weeks'  observation, 
in  order  to  become  acquainted  with  the  case 
in  its  individual  aspects,  to  learn  idiosyn- 
crasies, and  to  eliminate  the  factor  of  actual 
disease  as  a  causative  agent.  When  we 
demonstrate  to  our  satisfaction  that  the 
child  is  free  from  such  diseases  as  tubercu- 
losis, kidney  disease,  and  malaria;  when  we 
have  eliminated  by  properly  directed  treat- 
ment all  causes,  such  as  adenoids,  phimosis, 
adherent  clitoris,  vaginitis,  or  parasitic  and 
irritant  skin  lesions,  which  may  have  had 
a  deterrent  influence  upon  growth ;  and  when 
we  have  satisfied  ourselves  as  to  the  actual 


The  Delicate  Child  207 

condition  of  our  patient,  we  are  in  a  position 
to  lay  down  definite  rules  of  management. 

Every  child  has  a  distinct  function  to 
perform.  As  soon  as  he  is  born  he  is  con- 
fronted with  a  serious  problem — the  prob- 
lem of  growth,  physical  and  mental.  Inas- 
much as  this  growth  and  development  de- 
pend, above  all  things,  upon  a  properly 
adapted  food  supply,  it  must  be  our  first 
step  to  provide  such  nutriment  as  will  be 
most  conducive  to  it.  As  growth  takes  place 
in  all  parts  of  the  body  through  cellular 
activity,  the  nutritive  elements  which  sup- 
port cell  proliferation  must  be  important 
constituents  of  the  diet,  and  among  these 
the  proteids  are  of  prime  importance ;  hence 
in  the  management  of  these  children  a  point 
to  be  remembered  in  the  adaptation  of  the 
food  is  the  necessity  of  feeding  as  rich  a 
proteid  as  the  child  can  assimilate.  The 
younger  the  child,  the  greater  the  necessity 
for  growth. 

Regular  weighings  necessary.- — An  infant 
should  be  weighed  at  regular  intervals,  and 
if  under  one  year  of  age,  should  not  be  con- 
sidered as  doing  even  passably  well  if  not 
gaining  at  least  four  ounces  weekly.  When 


208          The  Delicate  Child 

a  baby  remains  stationary  in  weight  its 
development  is  invariably  abnormal.  When 
stationary  or  when  only  a  slight  gain  of 
one  or  two  ounces  weekly  is  made,  we  will 
always  find  after  a  few  weeks  that  there  is 
malnutrition,  in  spite  of  the  apparent  gain, 
as  will  be  evidenced  by  the  symptoms  of 
beginning  rickets— anaemia,  the  character- 
istic bone  changes,  flabby  muscles,  and  a 
tendency  to  disease  of  the  mucous  mem- 
branes. Delicate  infants  should  be  weighed 
daily  at  first ;  then,  as  improvement  takes 
place,  at  intervals  of  two  or  more  days,  but 
never  less  frequently  than  once  a  week,  if 
under  one  year  of  age,  no  matter  how  vig- 
orous they  may  become.  The  weighing 
keeps  us  directly  in  touch  with  the  child's 
condition,  but  since  the  increase  may  be  in 
fat  alone,  an  occasional  examination  of  the 
child  stripped  is  necessary  to  tell  us  whether 
there  is  substantial  growth  in  bone  and 
muscle. 

Feeding  delicate  infants. — When  it  is  de- 
monstrated that  a  child  will  not  thrive  on 
the  breast  of  the  mother,  another  breast 
should  be  substituted,  or  an  adapted  high- 
proteid  cow's  milk  should  form  the  diet  in 


The  Delicate  Child          209 

part  or  in  whole.  If  the  child  is  bottle-fed 
and  it  is  demonstrated  that  proper  growth 
and  development  are  impossible  on  cow's 
milk,  on  account  of  proteid  incapacity,  then 
a  wet-nurse  should  be  secured. 

When,  after  the  first  year,  more  liberal 
feeding  is  allowed,  the  necessity  for  a  high 
proteid  in  the  food  selected  is  as  urgent  as 
before.  This  applies  to  those  children  who 
are  brought  to  us  showing  evidences  of  late 
malnutrition,  as  well  as  to  those  whom 
we  have  had  under  our  care  from  early 
infancy. 

An  important  element  in  the  diet  up  to  the 
third  year,  is  milk.  A  child  from  the  first 
to  the  third  year  ought  to  receive  one  quart 
of  milk  daily.  Unfortunately,  many  debili- 
tated children  have  a  very  poor  capacity 
for  fat  assimilation.  When  given  full  milk 
in  as  small  an  amount  as  one  pint  daily, 
they  often  develop  foul  breath,  coated 
tongue,  and  loss  of  appetite,  or  they  sulVer 
from  frequent  attacks  of  acute  indigestion. 
The  milk  is  necessary,  not  because  ot  the 
fat,  which  can  easily  be  dispensed  with,  but 
because  of  the  high  percentage  o!  protenl 
which  it  contains — from  three  to  four  per 


210  The  Delicate  Child 

cent.  When  this  fat  incapacity  exists,  the 
milk  is  said  to  "disagree,"  but  skimmed 
milk  will  he  taken  without  inconvenience. 
Enough  sugar  may  be  added  to  bring  the 
percentage  up  to  seven,  in  order  that  it 
may  replace  the  fat,  for  fuel.  Skimmed 
milk  with  sugar  added  furnishes  a  food  of 
no  mean  order.  Too  much  milk,  however, 
must  not  be  given.  When  large  quantities, 
more  than  one  quart  daily,  are  taken,  the 
desire  for  more  substantial  nourishment, 
such  as  eggs,  meat,  and  cereals,  is  removed. 

At  the  completion  of  the  first  year,  keep- 
ing in  mind  a  high  proteid,  begin  with 
scraped  beef,  at  first  one  teaspoon ful  once 
a  day,  in  addition  to  the  cereal  and  milk. 
If  this  is  well  borne,  and  it  usually  is,  a  tea- 
spoonful  may  be  given  twice  a  day,  and 
later  three  times  a  day.  It  may  be  given 
immediately  before  the  bottle-feeding. 
Eggs  should  be  brought  into  use  from  the 
twelfth  to  the  fifteenth  month.  At  first 
one-half  an  egg,  boiled  two  minutes,  is  given 
mixed  with  bread-crumbs.  If  well  borne, 
a  whole  egg  may  be  allowed.  The  cereals 
used  should  be  those  most  rich  in  vegetable 
protein,  such  as  oatmeal,  containing  16  per 


The  Delicate  Child  211 

cent,  of  proteid,  dried  peas,  20  per  cent,  of 
proteid,  and  dried  beans,  containing  24  per 
cent,  of  proteid.  The  peas,  beans,  and  lentils 
should  be  given  in  the  form  of  a  puree. 

Diet  after  the  first  year. — If  the  child  during 
the  second  year  has  an  indifferent  appetite, 
reduce  the  quantity  of  milk;  never  allow 
more  than  one  pint  of  milk  daily  for  the  first 
week  or  two.  Many  delicate  children  who 
apply  for  treatment  after  the  first  year  of 
age  have  been  subjected  to  as  grave  errors 
in  diet  as  are  seen  among  the  bottle-fed. 
Starch  foods  and  milk  oftentimes  furnish 
the  only  means  of  nutrition  up  to  the  fourth 
or  fifth  year,  the  starch  used  being  generally 
in  the  form  of  bread,  crackers,  and  indif- 
ferently cooked  cereals.  In  one  case  four 
quarts  of  milk  were  taken  daily  by  a  boy 
of  seven  years. 

It  will  be  seen  that  it  is  our  aim  in  this 
class  of  children — the  delicate,  undersized, 
slow-growing  class — to  give  as  liberal  a 
nitrogenous  nourishment  as  is  compatible 
with  the  digestive  capacity  of  the  patient. 
But  if  the  child  has  had  rheumatism,  or  if 
there  is  a  tendency  to  lithiasis,  the  use  of 
a  lanie  amount  of  meat  is  contra-indicated. 


212  The  Delicate  Child 

It  is  in  such  children  that  the  high-proteid 
cereals  are  particularly  valuable.  In  a  gen- 
eral way,  from  early  life  the  diet  of  the 
delicate  child  should  consist  of  milk,  suit- 
ably adapted,  with  highly  nitrogenous  cereal 
added,  when  permissible.  Many  delicate 
children  of  the  "runabout"  age  who  cannot 
digest  milk  containing  4  per  cent,  of  fat  will 
easily  digest  butter  fat  \vhen  spread  on  bread 
or  potatoes.  In  this  way  I  often  use  it 
to  supply  fuel  to  act  as  a  proteid-sparer. 
Oatmeal-water  or  oatmeal- jelly,  mixed  with 
the  milk,  should  be  order  at  the  seventh 
month.  When  age  allows,  the  addition 
of  raw  or  rare  meat,  poultry,  eggs,  and 
purges  of  dried  peas,  beans,  and  lentils 
should  be  given.  Boxed  "ready  to  serve" 
cereals  are  never  given;  raw  cereals  are  used, 
which  are  cooked  three  hours.  While  a 
high-proteid  diet  is  desirable,  other  things 
are  necessary.  Green  vegetables,  animal 
fats,  the  ordinary  cereals,  cooked  and  raw 
fruits,  are  required  to  furnish  the  necessary 
acids  and  salts,  as  well  as  the  necessary 
variety.  In  short,  the  ideal  diet  for  a  deli- 
cate child  is  that  combination  of  food  which, 
while  imposing  the  least  burden  upon  the 


The  Delicate  Child  213 

digestive  organs,  supplies  the  body  with 
material  exactly  sufficient  for  its  needs,  and 
such  a  food  must  be  rich  in  nitrogen.  (See 
dietary,  page  73.) 

Baths. — On  account  of  the  fear  that  a 
delicate  child  may  take  cold,  the  bath  is 
often  omitted.  Every  child,  both  the  well 
and  the  delicate,  after  the  second  week 
should  be  tubbed  daily.  The  delicate  par- 
ticularly require  it.  The  salt  bath  (page 
117)  is  usually  advised.  The  best  time  for 
giving  the  bath  is  at  bedtime,  and  in  order 
to  avoid  all  chance  of  exposure  the  tempera- 
ture of  the  room  should  be  elevated  to  80°  F. 
The  temperature  of  the  water  may  vary. 
It  should  never  be  above  95°  F.  except  for 
very  delicate  young  children  in  whom  there 
is  a  tendency  to  a  subnormal  temperature. 
Even  in  these  cases  the  temperature  of  the 
bath  should  never  be  higher  than  the  tem- 
perature of  the  body.  In  the  frail  and  in 
the  very  young  the  bath  should  not  be  con- 
tinued over  five  minutes.  In  older  children, 
those  of  eighteen  months  or  over,  if  the  phys- 
ical conditions  allow,  a  distinct  advantage 
will  be  gained  by  a  reduction  of  the  tem- 
perature of  the  bath  while  the  child  is  in 


214  The  Delicate  Child 

the  water.  An  immersion  in  water  at  90°  F. 
followed  by  a  gradual  reduction  during  the 
space  of  rive  or  six  minutes  to  70°  F.  should, 
upon  brisk  rubbing,  be  followed  by  a  quick 
reaction.  If  the  reaction  is  not  good,  if  the 
extremities  are  cold  and  are  slow  in  becoming 
warm,  the  reduction  in  the  temperature 
should  lie  less  or  none  at  all.  In  the  very 
poorly  nourished,  a  reduction  below  80°  F. 
should  not  be  attempted.  Following  the 
drying  process,  primarily  for  the  benefit  of 
the  massage,  goose  oil  or  olive  oil  should  be 
rubbed  into  the  skin  over  the  entire  body 
for  from  five  to  ten  minutes.  The  bath 
and  the  massage  inunction,  besides  favor- 
ably influencing  nutrition,  are  a  very  effec- 
tive means  of  inducing  sleep. 

Fresh  u/r.-— Delicate  children  are  usually 
deprived  of  a  proper  amount  of  fresh  air, 
for  the  same  reason  that  they  are  insuf- 
ficiently bathed- —the  fear  of  making  them 
ill.  All  children  need  an  abundance  of 
fresh  air,  both  in  illness  and  in  health.  The 
robust  and  the  delicate  require  it,  and  to 
the  delicate  it  is  much  more  essential  than 
to  the  robust.  As  many  hours  daily  as 
practicable  should  be  spent  out  of  doors. 


The  Delicate  Child  215 

The  time  thus  spent  depends  upon  the 
season  of  the  year  and  the  residence  of  the 
child,  whether  in  the  city  or  the  country. 
In  the  city,  during  the  colder  months  with 
pleasant  weather,  the  child  should  spend 
at  least  five  hours  daily  in  the  open  air, 
dividing  the  day  into  two  outing  periods — 
from  9  to  11.30  in  the  morning  and  from  2 
to  4.30  in  the  afternoon.  On  very  cold 
days,  20°  F.  or  below,  on  stormy  days,  and 
on  days  with  very  high  winds,  the  child  is 
given  his  airing  indoors.  He  is  dressed  as 
for  out  of  doors,  placed  in  his  carriage,  and 
left  in  a  room,  the  windows  on  one  side  of 
the  room  being  open.  Not  infrequently 
during  February  and  March  delicate  chil- 
dren will  be  prevented  from  going  out  of 
doors  for  several  consecutive  days.  If  some 
means  for  a  daily  systematic  indoor  airing 
is  not  provided,  these  children  will  often 
go  backward,  no  matter  howr  excellent  the 
other  management.  The  first  symptoms 
arc  loss  of  appetite  and  the  ability  to  assimi- 
late the  food.  In  my  private  work  among 
marasmus  cases,  the  child  is  placed  in  the 
baby -carriage  or  in  a  basket  and  allowed 
to  rest  before  an  open  window  for  ten  or 


216  The  Delicate  Child 

twelve  hours  of  every  twenty-four,  with  a 
hot-water  bottle  at  his  feet.  Here  he  is 
fed,  being  removed  only  temporarily  to 
warmer  quarters  for  a  change  of  napkins. 
I  have  several  roof  gardens  in  operation. 
A  boy  patient  nine  months  of  age  has  been 
in  the  street  only  once  in  four  months,  then 
only  in  going  to  church  to  be  baptized. 

Sleep. — The  delicate  child  requires  no 
more  sleep  than  does  the  strong,  and  the 
rules  governing  this  matter  at  the  various 
periods  of  life  are  the  same  both  for  the 
strong  and  for  the  weak.  (See  Sleep,  page 
299.)  The  sleeping-room  of  the  delicate 
child  should  always  communicate  with  the 
open  air  by  a  window,  either  directly  or 
through  an  adjoining  room.  A  satisfactory 
method  of  ventilation  is  by  the  window- 
board  (page  13).  The  child  should  occupy 
the  room  alone,  if  possible,  sharing  it  neither 
with  an  adult  nor  another  child.  This  ap- 
plies to  all  ages,  but  is  particularly  neces- 
sary after  the  second  year. 

The  nursery. — The  temperature  of  the 
nursery,  day  or  night,  should  never  be  above 
70°  P.,  during  the  colder  months,  and  in 
the  case  of  the  very  young,  or  in  those  who 


The  Delicate  Child  217 

are  difficult  to  keep  covered,  it  should  not 
go  below  65°  F.  at  night. 

Delicate  children  of  the  "runabout"  age 
are  very  susceptible  to  colds.  In  the  man- 
agement of  such  children  it  is  necessary  to 
use  every  precaution  against  exposure.  The 
most  frequent  way  of  exposing  a  child  to 
cold  is  by  allowing  him  to  sit  on  the  floor. 
To  keep  the  child  of  from  ten  months  to 
three  years  of  age  off  the  floor  during  the 
winter  months,  and  thereby  to  eliminate 
this  means  of  exposure,  is  a  very  difficult 
matter.  In  fact  with  active  children,  learn- 
ing to  walk,  or  who  have  just  learned  to 
walk,  it  is  practically  impossible  under  the 
usual  conditions.  During  the  colder  months 
there  is  always  a  current  of  cold  air  near  the 
floor,  and  allowing  the  child  to  creep  in  win- 
ter, even  if  the  floor  is  protected  by  rugs 
and  carpets,  is  one  of  the  surest  ways  of 
permitting  him  to  take  cold.  If  he  is  allowed 
to  walk  on  the  floor  he  is  soon  very  sure  to 
sit  down.  If  he  is  not  allowed  to  creep  and 
walk  about  at  will,  he  will  not  get  the  proper 
exercise  and  will  show  faulty  development. 
For  such  cases  I  have  found  the  exercise 
pen  of  immense  service  (see  Fig.  g.).  After 


218  The  Delicate  Child 

being  dressed,  washed,  and  fed,  the  child  is 
placed  in  the  pen,  on  a  rug  if  desired.  Toys 
are  given  him  and  the  door  is  closed.  He 
can  now  roam  about  at  will,  stand  up,  sit 
down,  creep,  or  walk  without  the  slightest 
danger  from  drafts. 

Influence  of  climate.  — Much  has  been  writ- 
ten regarding  the  influence  of  climate  in 
the  type  of  case  we  are  considering.  Accord- 
ing to  my  observation,  this  matter  does  not 
deserve  the  attention  it  has  received.  The 
city  child  in  a  well-to-do  family  is,  as  a  rule, 
better  off  for  eight  months  of  the  year  in  his 
own  home  with  its  usual  conveniences.  The 
benefits  attributed  to  change  in  climate  are 
usually  the  result  of  a  change  not  of  climate 
but  to  more  fresh  air,  which  is  afforded  by 
the  larger  rooms  of  the  hotel,  with  its  loosely 
constructed  doors  and  windows;  and  since 
the  parent  is  desirous  that  the  child  shall 
receive  the  full  benefit  of  the  change,  he  is 
kept  in  the  open  air  for  a  much  longer  time 
than  when  at  home.  The  air  at  such  a 
place  is  more  expensive,  and  consequently 
more  appreciated  than  the  air  at  home. 
With  sufficient  heat  and  proper  ventilation, 
we  may  make  our  own  climate.  It  is  not 


The  Delicate  Child  219 

to  be  denied,  however,  that  a  change  of 
residence  for  a  few  weeks  from  New  York 
to  Lakewood  or  Atlantic  City  during  March 
and  April  is  sometimes  of  advantage. 

From  the  first  of  June  to  the  first  of  Octo- 
ber the  delicate  child  should  not  remain  in 
New  York  City.  The  humidity  and  the 
heat  which  may  prevail  for  protracted  periods 
during  this  time  render  it  unsafe,  particu- 
larly during  July  and  August.  The  sea- 
shore for  the  entire  summer  is  not  to  be 
advised.  The  children  whom  I  have  sent 
inland  to  the  country  and  to  the  mountains 
have,  as  a  rule,  returned  in  the  autumn  in 
a  much  better  physical  condition  than  those 
who  spent  the  summer  by  the  sea. 

Clothing. — Thin,  poorly  nourished  children 
require  more  clothing  than  do  those  phys- 
ically normal.  A  fairly  good  index  as  to 
whether  a  child  is  sufficiently  clad  is  the 
condition  of  his  lower  extremities.  The 
forearm  and  hand  cannot  be  relied  upon. 
The  legs  and  feet  of  every  child  should  always 
be  warm  to  the  touch. 

As  to  the  nature  of  the  clothing. — A  mixture 
of  silk  and  wool  next  to  the  skin  is  most 
desirable.  As  a  second  choice  a  mixture 


220  The  Delicate  Child 

of  wool  and  cotton  is  used.  The  linen  mesh, 
often  useful  in  the  vigorous  "runabout"  is 
not  to  be  advised  in  the  delicate. 

Exercise. — Moderate  exercise  is  to  be  en- 
couraged. But  it  should  never  be  allowed 
to  the  point  of  fatigue.  In  large  cities  all 
delicate  "runabouts"  from  three  to  five 
years  of  age  should  be  allowed  to  walk  not 
more  than  six  blocks  in  going  to  the  play- 
grounds. If  the  distance  is  greater,  the 
child  should  ride  part  of  the  way,  play  or 
walk  for  a  time,  and  then  be  placed  in  the 
carriage  or  cart  and  ride  home.  Younger 
children,  two  or  three  years  of  age,  should 
be  wheeled  both  ways  and  taken  out  at  the 
park  for  a  run  when  the  weather  conditions 
permit. 

Midday  nap. — Every  day  after  the  midday 
meal  the  child,  regardless  of  age,  whether 
two  years  or  six,  should  be  undressed  and 
put  to  bed  for  two  hours.  He  should  be 
left  alone  in  the  room,  and  whether  he  sleeps 
or  not  he  should  remain  in  bed  for  the  two 
hours. 

Entertainment. — Entertaining  play  is  neces- 
sary, but  every  kind  of  excitement,  such  as 
children's  parties,  emotional  plays  at  the 


The  Delicate  Child  221 

theatre,  and  rough  play  with  older  children, 
should  be  avoided. 

Education. — The  delicate  child  under  eight 
years  of  age  should  be  taught  only  to  the 
extent  of  strict  obedience  and  good  habits. 
Other  than  this  he  should  be  a  little  animal. 
There  should  be  no  teaching  in  the  ordinary 
sense  of  the  term,  no  mental  stimulation, 
until  the  child  is  physically  able  to  bear  it. 
When  school-work  begins,  which  in  this 
class  of  children  should  never  be  before  the 
eighth  year,  the  studies  should  be  made 
easy  and  the  school  hours  short.  Such 
children  should  never  be  crowded.  I  usu- 
ally direct  that  they  attend  only  the  morn- 
ing session. 

The  delicate  child  should  be  carefully 
watched  from  the  time  it  comes  into  our 
hands  until  it  reaches  the  normal  or  until 
the  period  of  development  is  completed. 
While  the  scheme  of  management  as  out- 
lined will  not  always  be  attended  with 
brilliant  results,  it  will  not  be  in  vain.  Many 
lives  will  be  saved,  and  as  a  result  of  the 
increased  acquired  resistance,  stronger  men 
and  women  will  be  added  to  the  race  than 
would  otherwise  have  been  possible. 


222     Premature  and  Weak  Infants 

PREMATURE     AND     COXGENITALLY 
WEAK  INFANTS 

There  are  comparatively  few  infants  horn 
before  the  completion  of  the  twenty -eighth 
week  of  pregnancy  that  survive  the  first 
year.  Reported  cases  of  survival  of  those 
horn  before  that  time  are  usually  unreliable, 
as  they  seldom  take  the  child  beyond  the 
third  month.  The  prognosis  is  influenced 
by  the  factors  causing  the  premature  birth. 

In  the  management  of  the  premature  and 
delicate  newly  born  there  are  three  points  to  be 
considered— the  air  the  child  gets  to  breathe, 
the  nourishment,  and  the  maintenance  of 
bodily  heat.  It  is  also  to  be  remembered 
that  we  are  dealing  with  an  undeveloped 
body  which  is  not  ready  for  the  environ- 
ment in  which  it  is  placed.  The  premature 
baby  should  be  handled  only  when  necessary, 
and  then  in  the  gentlest  manner.  Bathing 
is  often  best  omitted  for  the  first  few  weeks, 
oil  being  used  for  cleansing  purposes.  Be- 
cause of  the  undeveloped  parenchyma  of 
the  lungs  usually  good  fresh  air  is  required. 
Because  of  the  undeveloped  heat-centres 
the  body-heat  of  the  premature  infants  is 


Premature  and  Weak  Infants     223 

quickly  lost  and  must  be  maintained  by 
artificial  means.  The  stomach  is  small  and 
the  digestive  processes  arc  undeveloped  and 
weak,  so  that  the  nourishment  should  be  of 
the  most  easily  assimilable  character. 

The  maintenance  of  heat  is  of  the  utmost 
importance.  For  this  purpose  incubators 
and  their  various  modifications  have  been 
used  from  time  to  time.  .My  experience 
with  incubators  has  been  unsatisfactory. 
They  may  by  careful  watching  maintain 
an  even  temperature,  but  all  that  I  have 
used  have  been  defective  in  supplying  fresh 
air  to  the  child.  My  incubator  babies  have 
usually  done  badly.  Removal  from  the 
incubator  was  necessary.  If  the  electro- 
therm  (Fig.  12)  is  not  at  hand,  the  padded 
crib  with  the  child  wrapped  in  cotton  and 
surrounded  by  hot-water  bottles  is  the  best 
means  of  maintaining  the  temperature.  A 
thermometer  should  rest  between  the  cotton 
and  the  bed-clothing  as  a  guide  to  the  nurses 
in  the  use  of  the  hot-water  bottles.  Ordi- 
narily this  should  register  from  85°  to  95°  F., 
depending  upon  the  temperature  of  the 
child,  whose  rectal  temperature  should  at 
first  be  taken  frequently.  If  there  is  a 


224     Premature  and  Weak  Infants 

tendency  for  his  temperature  to  be  greatly 
reduced — below  95°  F. — more  external  heat 
will  be  necessary  than  if  the  temperature 


FIG.      12.    THE    ELECTROTHERM 


were  97°  or  98°  F.  The  best  device  among 
those  which  I  have  had  an  opportunity  to 
observe  for  maintaining  artificial  heat  is 
the  electrolherm  advocated  and  described 
by  Holt,  Diseases  of  Infancy  and  Childhood, 
1906. 

"These  small  heaters  are  attached  to  an 
electric  fixture,  like  a  drop-light.  A  con- 
venient size  is  from  ten  to  fifteen  inches. 
It  is  placed  between  two  or  three  thicknesses 
of  blankets,  upon  which  the  infant  lies  in 


Premature  and  Weak  Infants     225 

its  basket  or  crib.  The  degree  of  heat  can 
be  regulated  according  to  the  amount  of 
electricity  turned  on.  This  mode  of  hand- 
ling premature  infants  has  been  given  thor- 
ough trial  at  the  Babies'  Hospital  and  has 
been  found  to  fulfil  the  indications,  with 
children  as  small  as  three  pounds  and  as 
young  as  seven  months,  quite  as  well  as 
the  incubator,  while  at  the  same  time  being 
free  from  its  dangers.  It  has  not  been 
necessary  to  raise  the  general  temperature 
of  the  room.  These  patients  when  kept 
in  the  wards  at  an  ordinary  temperature 
have  maintained  an  even  bodily  tempera- 
ture much  more  uniformly  than  with  any 
other  method  I  have  seen,  the  incubator 
included." 

A  mistake  often  made  in  the  management 
of  premature  and  delicate  infants  is  that 
of  providing  too  warm  air  for  respiration, 
a  glaring  defect  in  most  incubators.  The 
best  means  of  decreasing  a  delicate  child's 
vitality  and  resistance  and  increasing  his 
chances  of  pulmonary  infection,  is  to  supply 
him  constantly  with  air  at  80°  to  90°  F. 
In  a  modern  house  the  maintenance  of  this 
temperature  usually  means  an  absence  of 


226     Premature  and  Weak  Infants 

change  of  air  and  an  abundance  of  bacteria. 
The  patients  do  best  when  the  temperature 
of  the  air  they  breathe  is  from  70°  to  72°  F. 
Breast-milk  for  premature  infants  born 
under  twenty-eight  weeks  is  almost  a  neces- 
sity, and  should  always  be  procured  when 
possible  for  all  premature  children.  The 
mother,  with  the  rarest  exception,  is  unable 
to  supply  it,  so  that  a  wet-nurse  should  be 
secured.  In  selecting  a  wet-nurse  for  a 
premature  baby  it  is  advisable  to  take 
the  wet-nurse's  baby  also,  as  Hie  prema- 
ture infant  may  not  be  able  to  nurse,  or 
if  he  nurses  he  will  not  take  all  the  milk. 
Pumping  the  breasts  of  a  wet-nurse  will 
almost  invariably  dry  them  up,  if  her  own 
baby  is  not  with  her  to  furnish  the  necessary 
stimulation  of  nursing.  Sufficient  milk  may 
be  removed  by  the  breast-pump  to  supply 
the  premature  infant  if  he  is  unable  to  nurse, 
and  the  wet-nurse's  baby  will  empty  the 
breast.  For  premature  babies  who  refuse 
the  breast  or  are  unable  to  take  a  nipple, 
the  Breck  feeder  (Fig.  13)  may  be  used  as 
a  means  of  giving  nourishment,  or  gavage, 
forced  feeding  with  a  tube,  may  be  brought 
into  use.  This  I  have  been  obliged  to  re- 


Premature  and  Weak  Infants     227 


sort  to  in  several  cases.  The  Breck  feeder 
consists  of  a  graduated  glass  tube,  nar- 
rowed at  one  end.  Over  this 
end  is  placed  a  small  rubber 
nipple,  the  other  end  being 
closed  by  a  flexible  rubber 
cap.  Drawing  on  the  nipple 
is  aided  and  encouraged  by 
pressure  on  the  air-filled  cap. 
If  the  breast-milk  proves  too 
strong  it  may  be  diluted  with 
equal  parts  of  a  6  per  cent, 
sugar  solution,  from  one-half 
to  one  ounce  of  the  mixture 
being  given  at  first  at  intervals 
of  from  one  to  one  and  one- 
half  hours.  Fourteen  to  fif- 
teen feedings  may  be  given 
in  the  twenty-four  hours,  the 
amount  depending  upon  the 
child's  digestive  ability.  If  hu- 
man milk  is  not  obtainable, 

rl(j.     1  j.         1  tit 

whey    made    from   whole  milk    HRKCK  FEEDER 
may  be  given,  or  one  ounce  of 
gravity  cream  may  be  given  with  one  ounce 
of  milk-sugar,  one  ounce  of  lime-water,  and 
fourteen    ounces    of    water.     Canned    con- 


228  Glands 

densed  milk,  one  part,  to  from  24  to  30  parts 
of  water,  may  be  used  with  advantage  as 
a  temporary  feeding  measure  when  nothing 
better  is  available.  The  food  strength  is 
increased,  the  intervals  made  longer,  and 
the  feeding  larger,  as  the  patient  proves  able 
to  assimilate  the  food. 

GLANDS 

ACUTE  ENLARGEMENT  OF  THE  GLANDS  OF  THE 
NECK 

A  mother  is  often  alarmed  by  the  sudden 
appearance  of  a  hard  swelling  in  the  neck 
of  one  of  her  children.  The  swelling  may 
appear  during  the  night  and  increase  greatly 
in  size  for  a  day  or  two,  when  it  may  be  as 
large  as  a  horse-chestnut.  Such  a  condition 
is  due  to  swollen  lymphatic  glands,  which 
are  usually  situated  just  behind  the  jaw  and 
below  the  ear.  Occasionally  the  swellings 
may  appear  in  the  soft  parts  under  the  jaw. 
The  glands,  in  the  performance  of  their 
functions,  have  become  infected  and  the 
swelling  follows.  The  cause  of  the  infection 
will  usually  be  found  in  a  lesion  of  the  mouth 
or  throat.  It  mav  sometimes  be  traced  to 


Glands  229 

a  lesion  of  the  skin  in  the  neighborhood  of 
the  swelling.  Thus,  the  source  of  infection 
may  be  a  decayed  tooth,  a  simple  abrasion 
of  the  mucous  membrane,  or  an  acute  inflam- 
mation of  the  part,  such  as  tonsillitis  or 
pharyngitis.  In  scarlet  fever  and  in  diph- 
theria the  glands  are  often  seriously  involved. 
The  glandular  enlargements,  however,  which 
appear  suddenly,  independent  of  serious  ill- 
ness, need  cause  no  great  anxiety.  They 
terminate  usually  in  one  of  two  ways:  they 
gradually  disappear  under  treatment,  or 
they  break  down  and  form  an  abscess  which 
requires  incision  and  drainage.  In  either 
event  complete  recovery  follows. 

If  the  swellings  occur  in  diphtheria  or  in 
any  other  infectious  disease,  they  may  con- 
stitute a  grave  complication.  With  their 
first  appearance,  apply  cold  compresses  to 
the  parts  constantly  until  the  physician 
arrives. 

CHRONIC  ENLARGEMENT  OF  THE  GLANDS  OF  THK 
NECK 

The  lymphatic  glands  of  the  neck  may  be 
chronically  enlarged  as  a  result  of  tubercu- 


230          The  Skin  in  Health 

losis,  syphilis,  or  local  infections  from  the 
skin,  and  a  lowered  general  vitality. 

The  mother  usually  notices  a  slight  swelling 
of  the  parts,  which,  upon  touch,  gives  the 
impression  of  a  hard  round  body  imme- 
diately beneath  the  skin;  usually  several 
of  these  nodules  will  be  discovered.  They 
often  extend  in  chains  down  the  side  of  the 
neck ;  sometimes  both  sides  will  be  involved. 
Bunches  of  glands  may  also  appear  under 
the  ear  and  at  the  angle  of  the  jaw.  They 
vary  in  size  from  a  buckshot  to  a  butternut. 

Children  with  a  tendency  to  enlargement 
of  these  glands  should  be  constantly  under 
medical  supervision. 

THE  SKIN  IN  HEALTH 

The  skin  of  an  infant  is  extremely  delicate 
and  great  care  is  required  to  keep  it  in  a 
healthy  condition.  The  secret  of  a  healthy 
skin  in  an  infant  is  in  proper  attention.  It 
must  be  kept  clean  and  dry.  After  the 
daily  bath,  in  which  no  ingredient  other  than 
plain  boiled  water  and  Castile  soap  should 
enter,  the  baby  must  be  carefully  dried  and 
the  folds  of  the  skin  and  flexures  of  the  joints 


Eczema  231 

thoroughly  powdered  with  equal  parts  of 
oxide  of  zinc  and  powdered  starch.  When 
the  napkins  are  soiled  they  should  be  changed 
at  once  and  the  parts  again  washed  and 
powdered.  An  occasional  sponging,  fol- 
lowed by  a  generous  use  of  powder  during 
very  hot  weather,  will  often  prevent  annoy- 
ing skin  affections,  such  as  prickly  heat  and 
eczema. 

ECZEMA 

Eczema,  a  catarrhal  inflammation  of  the 
skin,  is  a  disease  to  which  young  children 
are  very  susceptible.  It  appears  in  different 
forms,  which  means  that  there  are  several 
varieties  of  the  disease.  Any  portion  of 
the  skin  surface  may  be  involved.  The 
parts  most  frequently  affected  are  the  scalp, 
cheeks,  forehead,  and  the  flexures  of  the 
joints,  where  the  skin  surfaces  come  in  con- 
tact. The  cause  of  eczema  may  be  from 
within  or  without.  The  external  causes 
arc  all  of  the  nature  of  irritants.  A  baby's 
skin  is  very  delicate,  and  trifling  causes  will 
often  produce  a  great  deal  of  inflammation. 
Strong  soaps,  liniments,  a  sudden  exposure 


232  Eczema 

of  the  moist  skin  to  cold  air,  excessive  perspi- 
ration, insufficient  bathing,  discharge  from  the 
ear  or  nose,  all  may  cause  a  local  irritation 
and  produce  the  disease.  Allowing  a  child 
to  rest  in  a  soiled  napkin  is  a  most  frequent 
cause  of  eczema  of  the  buttocks,  a  condition 
which  is  elsewhere  referred  to.  The  treat- 
ment of  this  type  of  the  disease  resolves 
itself  into  removing  the  cause  and  protecting 
the  parts  by  means  of  a  suitable  ointment  or 
powder. 

Among  the  internal  causes,  indigestion 
is  by  far  the  most  frequent.  It  is  not  the 
delicate  child  who  suffers  most  from  eczema. 
In  many  instances  the  robust  nursling  and 
the  vigorous  bottle-fed  baby  are  the  sufferers. 
The  child  in  other  respects  appears  well,  has 
a  good  appetite,  is  bright  and  happy,  and 
shows  normal  development.  The  bright 
red  and  sometimes  weeping  area  on  each 
cheek,  and  the  itching,  scaly  forehead,  show 
clearly  that  something  is  wrong,  and  the 
error  will  usually  be  found  in  the  gastro- 
intestinal tract.  The  food  in  some  respect 
is  unsuitable,  not  being  properly  adapted 
to  the  child's  digestive  capacity.  In  the 
breast-fed,  regulation  of  the  life  of  the 


Eczema  233 

mother  as  regards  her  diet,  exercise,  and 
bowel  functions  will  often  effect  a  cure. 

In  the  bottle-fed,  an  adjustment  of  the 
food  to  the  child's  age  and  digestive  capacity 
and  attention  to  the  daily  bowel  evacuation 
aids  materially  in  the  treatment.  Consti- 
pation, if  present,  must  be  relieved.  Local 
treatment  with  ointments,  washes,  and  pow- 
ders are  all  of  little  value  if  the  cause  of  the 
disorder  is  not  removed.  The  case  may 
improve  temporarily  under  the  local  treat- 
ment, but  within  a  few  days  the  inflammation 
reappears  in  full  force. 

The  strait-jacket. — One  of  the  difficult 
features  of  treating  children  with  eczema 
is  the  tendency  for  the  child  to  scratch  the 


KIG.    14.       STRAIT-JACKET 


involved  parts.  This  not  only  keeps  up 
the  trouble  indefinitely  but  the  nails  are 
often  the  carriers  of  infection.  I  have  seen 


234 


Eczema 


not  only  severe  dermatitis,  but  furtmculosis 
and  cellulitis  develop  in  this  way.  One  of 
the  best  means  of  preventing  scratching  is 
in  the  modified  strait-jacket  (see  Fig.  14). 
The  jacket  is  made  of  muslin  and  must  be 
fitted  to  the  patient.  The  child  is  slipped 
into  the  jacket  feet  first.  The  opening  A 
encircles  the  thorax  directlv  under  the  arms. 


Fid.     15.       SI  KAIT-JACKKT    IN    POSITION 

The  opening  B  is  closed  about  the1  neck  \viih 
the  attached  tapes.  The  curd  \vhich  is  used 
to  close  the  end  of  the  sleeves  may  be  tied 
to  the  sides  of  the  crib  or  pinned  to  the  bed- 
ding. Children  readily  accustom  themselves 
to  the  position  of  lying  on  the  back  which 


Eczema 


235 


its  use  necessitates.  It  is  no  kindness  to 
allow  a  child  to  further  irritate  the  already 
badly  involved  surfaces. 


FIG.     1 6      MASK    PATTERN 

The  mask. — In  facial  eczema,  the  itching 
is  often  most  intense.  In  order  to  effect  a 
cure,  scratching  and  rubbing  of  the  parts  on 
any  object  with  which  the  child  may  come 
in  contact,  must  be  prevented.  The  Thomas 
mask  (see  Fig.  16)  answers  this  purpose  ad- 
mirably. The  ointment  or  lotion  is  placed 
on  clean  linen  which  rests  on  the  involved 
parts.  Over  this  is  placed  the  mask.  In 
Fig.  1 6  is  represented  a  pattern  of  the  mask. 


236 


Eczema 


Opening  A   is   sufficiently   large  to   furnish 
space  for  the  eyes,  nose,  and  mouth.     An 


KK;.   17.     MASK    IN  POSITION 

elastic  band  which  will  he  seen  to  pass  over 
the  upper  lip,  draws  the  sides  of  the  opening 
together,  insuring  protection  to  the  cheeks, 
usually  the  parts  chiefly  involved.  B  and  C 
pass  over  the  top  of  the  head  and  are  sewed 
to  D  and  E  which  pass  over  the  ears,  to 
the  back  of  the  head  where  they  are 
united.  The  masks  arc  best  made  of 


Hives  237 

muslin    or    thin  old   linen,  and   are  to    be 
renewed  daily. 

HIVES 

The  type  of  hives  most  frequently  seen 
in  children  appears  in  the  form  of  large 
wheals  from  one-half  to  one  inch  in  diameter. 
There  may  be  but  two  or  three  of  these 
wheals,  or  a  large  portion  of  the  body  may 
be  covered  by  them.  They  consist  of  a 
firm,  flat,  circumscribed,  reddened  eruption 
of  the  skin,  without  any  definite  arrange- 
ment. In  addition  to  the  skin,  the  mu- 
cous membrane  of  the  tongue,  mouth,  and 
pharynx  may  be  involved.  In  some  in- 
stances the  eruption  appears  very  suddenly, 
lasts  but  a  few  hours,  and  quickly  disap- 
pears. If  the  attack  is  of  a  severe  nature 
new  spots  appear  from  time  to  time  which 
behave  in  the  same  way.  Hives  in  children 
are  almost  without  exception  due  to  diges- 
tive disorders.  I  have  repeatedly  known 
attacks  to  follow  some  unsuitable  article 
of  diet,  such  as  cakes,  strawberries,  pastry, 
or  nuts.  Constipation  may  cause  an  attack. 

The  only  symptom  of  consequence  is  the 


238  Milk-Crust 

distressing  itching  which  is  always  present. 
Treatment  consists  in  the  use  of  laxatives 
and  a  temporarily  restricted  diet.  The  itch- 
ing is  best  relieved  by  bathing  the  parts  with 
a  solution  of  carbolic  acid — one  teaspoon- 
ful  to  a  pint  of  water. 

MILK-CRUST 

What  is  commonly  known  as  milk-crust 
consists  of  the  formation  on  the  scalp  of  a 
thick  layer  of  yellow  sebaceous  material. 
In  addition  to  being  unsightly  it  is  very- 
annoying  to  the  patient  on  account  of  the 
itching  which  it  causes.  The  mother  usually 
assures  us  that  the  condition  is  not  due  to 
neglect.  The  head  is  washed  and  oiled  very 
often;  but  washing  will  neither  cure  nor  pre- 
vent the  disease. 

Milk-crust  is  due  to  an  inflammation  of 
the  sebaceous  glands  of  the  skin.  The  affec- 
tion is  easily  relieved.  The  hair  must  be 
cut  very  short,  and  an  ointment,  composed 
of  resorcin,  forty  grains,  and  vaseline,  two 
ounces,  should  be  spread  generously  over 
the  diseased  area  and  covered  with  a  piece 
of  linen  which  has  been  saturated  with  the 


Intertrigo  239 

ointment.  Over  this  a  fairly  tight-fitting, 
home-made  muslin  cap  should  be  worn  to 
hold  the  dressing  in  place.  The  ointment 
should  be  applied  twice  daily.  After  three 
or  four  days  of  the  treatment,  during  which 
time  no  water  must  touch  the  scalp,  it  may 
be  gently  cleansed  with  Castile  soap  and 
warm  water,  or  with  warm  sweet  oil. 

The  whole  or  the  greater  portion  of  the 
crusts  may  be  removed  with  the  first  washing. 
Some  severe  cases  may  require  two  or  three 
repetitions  of  the  treatment.  After  the 
scalp  is  clean,  an  application  of  the  oint- 
ment at  bedtime  once  or  twice  a  week  will 
prevent  a  return  of  the  trouble. 

IXTERTRIGO 

Inflammation  of  the  skin  of  the  thighs 
and  buttocks,  by  some  mothers  erroneously 
called  sprue,  is  often  seen  in  quite  young 
children.  In  the  majority  of  cases  this 
condition  is  due  solely  to  neglect  of  the 
toikl.  The  child  is  allowed  to  lie  in  soiled 
napkins,  the  irritant  discharges  thus  remain- 
ing in  contact  with  the  delicate  skin,  and 
inflammation  and  excoriation  of  the  parts 


240  Intertrigo 

naturally  follow.  Children  have  delicate 
skins  and  often  pass  very  acid  urine.  When 
this  combination  is  present  an  inflammatory 
condition  of  the  parts  is  frequently  difficult 
to  avoid.  The  management  is  simple, 
usually  requiring  only  a  changing  of  the 
napkin  as  soon  as  soiled  and  the  generous 
use  of  zinc  ointment.  I  have  had  very  little 
success  with  dusting  powders  in  such  cases, 
especially  in  those  of  any  degree  of  severity. 
After  passage  either  from  the  bladder  or 
bowels,  the  napkin  should  be  immediately 
removed,  the  parts  gently  washed  with 
Castile  soap  and  boiled  water,  or,  in  bad 
cases,  warm  sterilized  sweet  oil  may  be  used 
to  better  advantage.  After  the  parts  are 
clean,  apply  to  the  inflamed  area  pieces  of 
clean  old  linen  which  have  been  covered  with 
zinc  ointment.  If  the  ointment  is  applied 
directly  to  the  skin  the  napkin  soon  absorbs 
it,  and  its  application  will  be  of  no  service. 
The  ointment  acts  as  a  barrier  between  the 
irritating  passages  and  the  inflamed  skin. 
Under  this  treatment  I  have  repeatedly 
seen  the  worst  cases  of  intertrigo  recover 
in  a  week. 

Of   course   the   applications    must   be   re- 


Prickly  Heat  241 

peated  after  each  cleansing  and  drying. 
The  ointment  must  be  used  extravagantly. 
The  dressing  is  then  applied  to  the  parts 
and  is  to  be  changed  several  times  daily. 
Over  this  dressing  the  napkin  is  placed,  and 
is  to  be  changed  several  times  daily.  If 
the  ointment  is  simply  spread  over  the  skin 
and  the  napkin  applied,  it  will  soon  be  ab- 
sorbed by  the  napkin  and  be  of  no  service. 
The  urine,  which  is  chiefly  at  fault,  is  pre- 
vented by  the  ointment  dressings  from 
coming  in  contact  with  the  skin,  the  treat- 
ment being  solely  protective.  At  the  same 
time  a  quantity  of  absorbent  cotton  is  placed 
next  to  the  genitals  so  as  to  absorb  the  urine 
as  it  is  passed  and  thus  prevent  its  general 
distribution  over  the  parts.  When  the  case 
is  well  advanced  towrard  recovery,  scrupulous 
cleanliness  and  a  dusting-powder  composed 
of  equal  parts  of  powdered  starch  and  oxide 
of  zinc  will  usually  be  all  that  is  required. 

PRICKLY  HEAT 


In  prickly  heat  there  is  an  acute  engorge- 
ment of  the  vessels  of  the  sweat-glands  with 

obstruction  to  their  outlet.      Minute  papules 
16 


242  Prickly  Heat 

form  which  arc  reddish  in  color.  The  mild 
cases  are  without  inflammation.  When  in- 
flammation develops,  small  vesicles  also 
appear  and  may  cover  large  areas  of  the 
body.  Nearly  every  infant  sutlers  from 
prickly  heat  in  summer.  It  is  most  fre- 
quently seen  on  the  head  and  neck  and  over 
the  chest  and  shoulders.  The  patients  are 
very  uncomfortable  and  restless.  There  is 
evidently  a  great  deal  of  burning  and  itching. 
The  condition  is  caused  by  heat,  clue  either 
to  too  much  clothing  or  to  the  hot  weather 
of  summer;  both  causes  may  be  operative. 
I  have  frequently  seen  it  in  winter  in  over- 
clad  children.  Most  babies  are  overclad  at 
all  seasons  of  the  year.  When  prickly  heat 
develops,  regardless  of  the  season,  it  is  a 
sure  sign  that  the  child  has  been  kept  too 
warm.  The  duration  is  dependent  upon 
climatic  conditions  and  also  upon  the  treat- 
ment. 1  have  seen  eases  which  have  existed 
for  months. 

Heavy  clothing  and  flannels  are  to  be 
avoided.  The  clothing  should  be  light  in 
weight  and  of  loose  texture.  In  order  !o 
lessen  the  local  irritation  the  garment  worn 
next  to  the  skin  mav  be  lined  with  silk,  linen, 


Prickly  Heat  243 

or  gauze.  The  further  means  of  manage- 
ment as  regards  both  the  relief  afforded  the 
patient  and  the  cure  of  the  condition,  con- 
sists in  the  frequent  application  of  cool  water, 
in  the  form  of  either  a  tub-bath  or  sponging. 
The  soda  bath,  the  bran  bath,  and  the  starch 
bath  (page  117)  are  all  most  useful.  For 
purposes  of  sponging,  a  solution  of  bicar- 
bonate of  soda  should  be  used — one  table- 
spoonful  to  a  gallon  of  water.  The  relief 
afforded  the  patient  depends  not  so  much 
upon  what  is  used  in  the  water  as  upon  the 
fact  that  plenty  of  cool  water  comes  in  con- 
tact with  the  itching,  burning  skin.  Oint- 
ments and  salves  are  of  little  service  here, 
as  they  tend  to  produce  further  maceration 
of  the  skin.  As  local  applications,  powders 
are  preferred  tb  lotions.  A  powder  used 
with  satisfaction  in  this  condition  is  of  the 
following  composition : 

ft    Boracic  acid,  60  grains. 

Powdered  starch,  ) 

T,       .        .       .  ,       ...        >  each  i  ounce. 

Powdered  oxide  of  zmc,  \ 

This  is  to  be  dusted  freely  over  the  involved 
surface  several  times  daily,  every  hour  if 
necessary. 


244         Fissures  of  the  Anus 

FISSURES  OF  THE  ANUS 

In  children  suffering  from  what  are  called 
fissures  of  the  anus  there  will  be  found  one 
or  more  slight  tears  in  the  mucous  membrane 
just  inside  the  anal  aperture.  In  such  cases 
there  is  always  a  history  of  an  intestinal 
disorder,  usually  constipation,  sometimes 
diarrhoea,  the  fissures  having  been  caused 
either  by  a  stretching  of  the  parts  by  a  hard, 
constipated  movement,  or  by  the  frequent 
irritant  passages  which  have  caused  a  de- 
struction of  the  mucous  membrane  of  the 
parts. 

An  infant  thus  affected  cries  lustily  when 
having  a  passage,  and  strains  and  presses 
for  some  time  afterward.  Very  often  the 
passage  will  be  streaked  with  blood.  Older 
children  postpone  going  to  stool  as  long  as 
possible  and  complain  greatly  of  pain  when 
the  bowels  move. 

These  cases  will  be  greatly  relieved  by 
the  correction  of  the  intestinal  derangement. 
If  the  child  is  constipated,  the  movements 
should  be  kept  soft  by  the  use  of  suitable 
diet  and  laxatives.  If  there  is  diarrhoea, 
suitable  diet  and  medical  attention  are 


Boils  245 

necessary.  The  local  treatment,  which  may 
be  necessary,  should  be  carried  out  by  a 
physician. 

BOILS 

Infants  are  particularly  subject  to  boils, 
which  are  supposed  by  many  to  indicate 
some  radical  blood  disorder.  As  a  result, 
the  victims  are  drugged  and  purged  with 
all  sorts  of  teas  and  "blood -purifiers."  The 
cause  of  the  boil  is  very  rarely  from  within. 
It  is  usually  the  result  of  a  local  infection 
or  inoculation  into  the  skin,  the  germs 
finding  entrance  by  means  of  a  hair  follicle 
or  an  abrasion  so  small  as  to  be  invisible  to 
the  naked  eye.  A  boil  having  formed,  the 
pus  is  carried  to  other  portions  of  the  skin 
by  the  lymphatics,  or  it  escapes  upon  the 
surface,  and,  in  either  case,  other  portions 
of  the  skin  are  inoculated,  and  a  series  of 
boils  results.  The  parts  most  often  involved 
are  the  head,  the  neck,  and  the  shoulders, 
although  they  may  appear  upon  any  portion 
of  the  body,  with  the  exception  of  the  palms 
of  the  hands  and  the  soles  of  the  feet.  I 
have  opened  one  hundred  and  four  on  one 


246  Burns 

child  during  a  period  of  three  weeks.  While 
boils  are  more  frequently  met  with  among 
the  debilitated  and  weakly,  they  are  by  no 
means  uncommon  in  the  strong  and  other- 
wise well.  Poulticing,  and  allowing  a  boil 
to  open  spontaneously,  is  calculated  to  pro- 
long the  trouble  indefinitely.  A  boil  should 
be  opened  early,  the  pus  evacuated,  and  the 
surrounding  skin  thoroughly  washed  with 
soap  and  water,  when  an  antiseptic  dressing 
composed  of  several  thicknesses  of  old  linen, 
which  has  been  boiled  and  dried  and  then 
dipped  into  a  saturated  solution  of  boracic 
acid,  answers  ever}-  purpose.  Not  only 
the  boil  but  the  adjacent  skin  for  several 
inches  must  be  covered  by  the  dressing, 
which  is  to  be  kept  wet  with  the  boracic  acid 
solution. 

BURNS 

The  temporary  treatment  of  a  burn  of 
any  degree  aims  at  the  exclusion  of  the  air 
by  the  application  to  the  injured  parts  of 
some  non-irritating,  oily  substance,  such  as 
vaseline,  zinc  ointment,  or  sterilized  sweet- 
oil.  A  piece  of  clean  linen  is  saturated  with 


Head  Lice — Pediculi  Capitis      247 

the  ointment  and  placed  upon  the  parts 
affected,  and  kept  there  until  the  arrival 
of  the  physician. 

HEAD  LICE— PEDICULI  CAPITIS 

Head  lice,  or  pediculi  capitis,  are  very 
frequently  seen  in  out-patient  and  hospital 
work  among  children  in  all  the  larger  cities. 
Occasionally  other  children  become  infected 
in  school  or  in  public  conveyances  who  carry 
the  vermin  to  other  members  of  the  family. 
The  most  successful  and  cleanly  treatment 
consists  in  cutting  the  hair  short ;  this  done, 
wash  the  head  with  soap  and  water  once  a 
day,  and  after  drying  moisten  the  scalp 
thoroughly  with  the  following  solution  twice 
daily : 

Acetic  acid 2  drachms. 

Sulphuric  ether 3  ounces. 

Tincture   of  larkspur,  j 

0   .  .        .    .  f  or  each  4  ounces. 

opints  vim  rect.,  ) 

Improvement  will  follow  a  few  treatments. 
The  pediculi  will  be  killed  and  the  nits  may 
be  removed  with  a  fine-tooth  comb.  If 
the  patient  is  a  girl  it  is  not  absolutely 


248  Bites  of  Animals 

necessary  to  sacrifice  the  hair.  It  may  be 
parted  from  various  portions  of  the  scalp 
and  the  solution  applied  without  previous 
washing.  However,  if  the  hair  is  not  cut, 
a  much  longer  time  will  be  required  to 
effect  a  cure. 

BITES  OF  INSECTS 

Bites  of  insects  in  this  country  are  rarely 
dangerous,  although  they  sometimes  cause 
great  temporary  disfigurement.  It  is  quite 
difficult  often  to  distinguish  between  insect 
bites  and  the  eruption  of  hives.  Mosquitoes 
poison  some  infants  severely. 

Insect  bites  are  best  treated  by  the  use 
of  a  solution  of  carbolic  acid, — one-half 
teaspoonful  to  a  pint  of  water.  This  is 
applied  by  means  of  old  linen  which  is  kept 
saturated  with  the  solution. 

BITES  OF  ANIMALS 

Bites  of  animals  rarely  amount  to  more 
than  an  incised  wound  from  any  other  cause, 
and  the  treatment  required  is  practically 
the  same.  When  a  child  is  bitten  by  a  dog 


Fever  249 

or  a  cat  the  parents  are  greatly  alarmed 
lest  the  child  develop  hydrophobia.  If, 
however,  they  will  remember  that  dogs  bite 
thousands  of  people  every  year  and  no  harm 
comes  from  it,  if  they  will  remember  that  a 
mad  dog  is  of  the  rarest  occurrence,  they 
will  waste  much  less  good  nerve  force  upon 
what  is  usually  a  trifling  matter.  In  case 
of  a  bite  of  any  animal,  dissolve  one  tea- 
spoonful  of  carbolic  acid  in  one  pint  of  water, 
and  keep  the  parts  moist  with  the  solution, 
using  only  clean  linen  for  its  application  to 
the  wound.  The  physician,  who  should  be 
called  at  once,  will  advise  further  treatment 
if  needed. 

FEVER 

By  fever  we  understand  an  elevation  of 
the  temperature  of  the  body  above  the 
normal,  which  in  an  infant  is  99°  F.  +  by 
rectum.  Fever,  however,  does  not  con- 
stitute disease.  It  is  nothing  more  or  less 
than  a  symptom,  but  it  always  means  that 
something  is  wrong  with  the  baby.  It  may 
be  due  to  a  slight  attack  of  indigestion,  the 
eruption  of  teeth,  or  to  the  beginning  of 


250  Fever 

scarlet  fever,  diphtheria,  or  some  other 
disease.  Children  develop  fever  much  more 
readily  than  adults,  and  it  is  of  less  signi- 
ficance in  them.  A  child  with  fever  that 
is  appreciable  to  the  touch  of  the  mother 
will  usually  register  a  temperature  of  100.5° 
-101.5°  F.  While  such  a  temperature  is 
by  no  means  alarming,  its  cause  should  be 
discovered.  In  the  absence  of  a  clinical 
thermometer,  in  order  to  examine  a  baby 
for  fever,  place  upon  the  abdomen  the  palm 
of  a  hand  which  has  been  previously  warmed. 
Examination  of  a  child's  hands,  head,  and 
feet  furnishes  us  very  inexact  means  of 
judging  as  to  the  question  of  fever.  Many 
times  these  parts  will  be  cold  when  the 
thermometer  registers  a  temperature  of  104° 
or  105°  F.  Even-  young  mother  should  pos- 
sess, and  know  how  to  use,  a  clinical  ther- 
mometer. In  case  of  sudden  high  fever,' — 
104°  to  105°  F.,-— from  any  cause,  the  mother 
cannot  make  a  mistake  in  giving  an  alcohol 
and  water  sponge-bath  at  a  temperature  of 
85°  V.  One  part  of  alcohol  may  be  added 
to  3  parts  of  water  and  the  child  sponged 
for  twenty  minutes.  If  necessary  the:  spong- 
ing may  be  repeated  even,-  two  or  three 


Malaria  251 

hours;  this  will  keep  the  child  comfortable 
until  the  arrival  of  the  physician  and  per- 
haps prevent  unpleasant  complications.  In 
case  of  fever  the  nourishment  should  always 
be  reduced  at  once;  if  the  child  is  on  the 
bottle,  reduce  the  strength  of  the  food  one- 
half  by  the  addition  of  boiled  water.  If 
the  child  is  nursed,  reduce  the  duration  of 
each  nursing  period  one-third.  Children 
with  fever  can  always  have  plenty  of  cold 
boiled  water  to  drink.  Mothers  must  re- 
member that  it  is  not  the  fever  per  se,  but 
the  condition  of  the  patient,  which  governs 
us  in  our  treatment.  In  scarlet  fever  and 
pneumonia,  a  temperature  of  102°  to  104°  F. 
is  expected,  and  need  cause  no  alarm. 

MALARIA 

Children  in  New  York  City  and  vicinity 
occasionally  suffer  from  malarial  fever. 
Fewer  cases  come  under  my  observation 
now  than  formerly.  The  disease  manifests 
itself  in  three  different  sets  of  symptoms. 
The  mild  form  is  most  frequently  seen,  and 
will  be  the  first  considered. 

The  first  signs  of  the  illness  are  drowsi- 


252  Malaria 

ness,  languor,  disinclination  to  play,  and 
loss  of  appetite.  In  addition,  such  a  child 
is  apt  to  be  peevish  and  fretful;  he  falls 
asleep  at  unusual  times  during  the  day. 
The  sleep  at  night  is  often  disturbed,  and 
he  generally  sleeps  later  in  the  morning. 
There  is  a  little  fever, — so  slight  that  it  is 
not  appreciable  to  the  touch.  These  symp- 
toms are  followed  by  pallor  and  loss  of  weight. 
Such  a  condition  may  exist  for  several  weeks 
without  the  development  of  more  active 
symptoms  of  the  disease. 

In  the  more  typical  cases,  the  fever,  lan- 
guor, and  drowsiness  will  appear  at  a  definite 
time  each  day,' — usually  from  three  to  five 
o'clock  in  the  afternoon.  The  child  wakes 
the  following  morning  apparently  well,  but 
at  about  the  same  hour  in  the  afternoon 
the  symptoms  are  repeated.  There  is  always 
a  distinct  periodicity  in  the  symptoms.  In 
some  cases  the  child  will  lie  ill  every  second 
day,  but  at  the  same  hour.  In  other  cases 
the  symptoms  are  still  more  characteristic 
and  are  easily  recognized.  At  a  certain 
time  every  day,  or  perhaps  every  second 
or  third  day,  there  will  be  a  chill  and  a 
rapid  rise  in  temperature,  followed  by  a 


Tuberculosis  253 

profuse  perspiration,  during  which  the  fever 
subsides. 

I  recently  treated  a  little  girl  five  years 
of  age  who  had  a  chill  every  second  day  at 
eleven  o'clock  in  the  morning.  The  fever 
rose  rapidly,  until  at  one  o'clock  it  was  106°; 
at  3.30  the  temperature  was  normal,  and 
the  child  felt  perfectly  well.  This  continued 
for  one  week. 

The  diagnosis  in  the  first  class  of  cases  is 
by  no  means  easy.  In  many  instances  the 
nature  of  the  illness  is  not  discovered  and 
the  child  is  treated  for  various  imaginary 
ills. 

The  usual  treatment  of  malaria  in  children 
is  by  the  use  of  quinine,  or  by  a  change  of 
climate.  The  majority  of  the  cases  recover 
satisfactorily  under  quinine,  but  it  should 
never  be  given  without  a  physician's  order. 
The  indiscriminate  giving  of  quinine  when- 
ever a  child  falls  ill  cannot  be  too  strongly 
condemned. 

TUBERCULOSIS 

Tuberculosis  is  an  infectious  disease  which 
carries  off  one-seventh  of  the  population  of 


254  Tuberculosis 

the  earth.  Children  arc  very  susceptible 
to  the  infection.  The  disease  is  caused  by 
the  entrance  into  the  system  of  a  micro- 
organism known  as  the  tubercle  bacillus. 
Tuberculosis  is  not  inherited.  The  disease 
always  comes  from  without,  as  does  typhoid 
fever  or  diphtheria.  We  often  see  parents 
and  children  in  turn  sicken  and  die  with 
this  disease.  This  does  not  necessarily  mean 
heredity,  however.  It  means  that  there  is 
a  family  condition  of  constitution  which 
furnishes  a  favorable  soil  for  the  develop- 
ment of  the  bacillus.  If  all  who  swallowed 
or  inhaled  the  tubercle  bacillus  became 
tubercular,  the  earth  would  be  depopulated 
in  a  very  few  years.  \Ve  have  all  taken  the 
tubercle  bacillus  into  our  bodies  at  some 
time,  probably  many  times.  In  one  indi- 
vidual the  germ  finds  a  favorable  soil  and 
flourishes;  in  another,  unfavorable  condi- 
tions,— health  and  vigor  of  constitution,-  - 
and  it  dies.  The  usual  means  of  infection 
is  through  the  inspired  air  by  the  inhalation 
of  the  infected  dust  from  the  public  convey- 
ances, from  the  street,  or  from  infec'ed 
dwellings.  Infection  niay  also  take  place 
by  direct  contact  through  kissing.  The 


Tuberculosis  255 

bacillus  may  be  swallowed  with  food  or 
drink  which  has  been  contaminated. 

Almost  every  portion  of  the  body  may 
become  the  seat  of  the  tubercular  process. 
When  the  micro-organism  attacks  the  lungs, 
it  produces  what  is  known  as  consumption, 
or  pulmonary  tuberculosis.  When  the  cov- 
ering of  the  brain  is  involved,  the  child  has 
tubercular  meningitis.  When  the  hip-joint 
is  attacked,  hip-disease  follows.  When  the 
spine  is  attacked,  it  produces  what  is  known 
as  Pott's  disease.  When  the  glands  of  the 
neck  are  infected,  scrofulous  glands  or  tuber- 
cular adenitis  is  the  outcome.  Tubercular 
disease  of  the  knee  is  commonly  known  as 
white  swelling.  These  are  the  parts  which 
are  most  frequently  the  seat  of  the  tuber- 
cular process.  With  less  frequency  the 
bacillus  attacks  the  bladder,  the  kidneys, 
the  skin,  the  intestines,  the  mesenteric  glands, 
and  the  peritoneum. 

In  institutions  and  among  the  poor,  what 
is  known  as  general  tuberculosis  causes  the 
death  of  many  infants.  At  autopsy  they 
show  an  involvement  of  nearly  all  the  in- 
ternal organs.  Tuberculosis  in  children  is 
alwavs  a  verv  serious  disease1,  but  it  is  not 


256  Rickets 

necessarily  fatal ;  many  cases  recover.  When 
the  disease  involves  the  spine,  hip-joint,  or 
knee-joint,  or  the  glands  of  the  neck,  the 
prognosis  as  regards  life  is  usually  good. 
When  the  brain  is  attacked.it  is  always  fatal. 
In  tubercular  disease  of  the  lungs  in  very 
young  children  the  prognosis  is  very  grave. 
Many  older  children — those  from  seven  to 
eight  years  of  age — recover  if  the  disease 
has  not  progressed  too  far  before  coming 
under  treatment.  The  important  features 
in  the  management  of  these  cases  are:  change 
to  a  dry  climate  at  an  elevation  of  one  thou- 
sand to  fifteen  hundred  feet,  with  close  atten- 
tion to  hygiene  and  a  carefully  regulated  diet 
in  which  there  should  be  a  generous  allowance 
of  meat,  eggs,  and  milk. 

RICKETS 

Rickets  is  a  constitutional  disease  due 
to  malnutrition.  A  child  with  rickets  either 
has  not  received  suitable  nourishment,  or, 
if  he  has  received  it,  it  has  not  been  assimi- 
lated. Lack  of  nourishment  manifests  itself 
in  characteristic  changes  in  the  bones,  mus- 
cles, and  in  the  nervous  system.  In  addition 


Rickets  257 

to  their  physical  characteristics,  children 
with  this  disease  may  show  delayed  mental 
development.  A  nchitic  child  is  usually 
under  weight  and  undersized,  particularly 
as  regards  length.  The  head  is  ill-shaped, 
the  enlargement  of  certain  bones  of  the  skull 
giving  the  head  a  square  appearance.  The 
sutures  and  fontanelle  close  very  late.  I 
have  seen  the  fontanelle  still  open  at  the 
fourth  year.  The  teeth  are  cut  late,  are  apt 
to  be  soft,  and  decay  early.  Many  rachitic 
children  do  not  get  the  first  teeth  until  after 
the  twelfth  month  is  passed.  The  chest  is 
narrow  and  depressed  at  the  sides,  and  along 
its  anterior  portion,  at  the  junction  of  the 
costal  cartilages  with  the  ribs,  a  row  of 
nodules  can  be  traced.  The  ends  of  the 
long  bones,  particularly  at  the  wrists  and 
ankles,  are  very  much  enlarged.  In  many 
cases  this  enlargement  is  so  great  that  it 
produces  quite  a  deformity.  Often  the  legs 
are  curved,  a  condition  known  as  "bow- 
legs."  The  spine  is  weak  and  in  severe 
cases  the  child  is  unable  to  sit  erect.  Spinal 
curvature  is  frequently  seen  in  these1  children. 
The  abdomen  is  usuallv  vcrv  prominent. 
The  malnutrition  is  further  shown  bv  the 


258  Rickets 

flabby,  poorly  developed  muscles,  by  the 
tendency  to  perspiration,  particularly  about 
the  head,  and  by  the  unstable  nervous  sys- 
tem. These  children  are  restless,  irritable, 
and  hard  to  please,  and  they  have  convul- 
sions under  slight  provocation.  Not  all 
rachitic  children  are  below  weight;  some 
are  quite  fat,  but  pale  and  flabby.  The 
changes  in  the  bones,  however,  are  similar 
in  both  types.  In  addition  to  the  charac- 
teristics noted,  rachitic  children  possess 
feeble  powers  of  resistance.  They  are  prone 
to  catarrhal  affections  of  the  respiratory 
and  intestinal  tracts.  In  many  instances, 
they  teeth  late  and  with  much  difficulty. 
On  account  of  their  enfeebled  condition  and 
lack  of  resistance,  illness  in  a  rachitic  child 
is  apt  to  be  tedious,  if  not  serious. 

The  prevention  of  rickets  depends  upon 
proper  feeding.  Condensed  milk  and  the 
proprietary  meal  foods  are  responsible  for 
a  large  majority  of  the  cases.  Proper  man- 
agement requires  suitable  food,  cleanliness, 
fresh  air,  and  cod-liver  oil.  By  "suitable 
food"  is  meant  good  milk  for  children  under 
one  year,  to  which  meat  and  eggs  are  added 
as  soon  as  thev  can  be  digested — usually 


Scurvy  259 

after  the  twelfth  month.     For  very  rachitic 
children  I  order  also  one  brine  bath  daily. 

SCURVY 

Scurvy  is  a  disease  of  quite  frequent 
occurrence  among  bottle-fed  children.  It 
is  characterized  by  pain  in  one  or  more  of 
the  joints  of  the  long  bones,  with  or  without 
swelling  of  the  involved  parts  and  discolored, 
spongy,  or  bleeding  gums.  Hemorrhages 
into  the  skin  sometimes  occur,  which  give 
the  child  a  peculiar  mottled  appearance. 
The  disease  is  often  mistaken  for  rheuma- 
tism because  of  the  swollen  and  painful 
joints.  If  the  case  is  a  very  severe  one  it 
may  resemble  paralysis  in  some  of  its  aspects. 

The  disease  is  clue  to  errors  in  nutrition. 
The  great  majority  of  the  cases  develop  in 
those  who  are  being  fed  on  proprietary  meal 
foods,  condensed  milk,  and  overcooked  cows' 
milk. 

Among  the  author's  sixty-four  cases,  one 
symptom  was  always  present:  They  all 
showed  evidences  of  faulty  nutrition;  they 
also  presented  another  symptom  in  common 
which  was  the  earliest  active  manifestation  of 


260  Scurvy 

the  disease,  and  that  was  pain.  The  child 
that  has  been  playful,  active,  and  has  enjoyed 
attention,  suddenly  undergoes  a  change- 
he  prefers  to  rest  in  the  crib  or  carriage, 
cries  when  handled,  and  refuses  to  play. 
Often  the  first  signs  of  trouble  will  be  noticed 
when  changing  the  napkin  or  putting  on 
the  shoes  or  stockings.  The  movement  of 
the  diseased  parts  causes  pain  and  the  child 
cries  lustily.  If  he  is  undressed  and  rests 
on  his  back,  the  affected  limb  in  all  prob- 
ability will  remain  motionless,  while  its 
companion  may  be  moved  freely. 

The  symptom  of  pain  appears  before  the 
swelling  of  the  joints,  which  is  sure  to  follow 
in  case  the  disease  is  not  recognized  early 
and  treated  properly.  Another  character- 
istic symptom  is  the  swollen,  congested,  and 
bleeding  gums  about  the  upper  incisor  teeth. 
This  condition  is  sometimes  seen  early  in 
the  attack,  but  it  is  usually  a  later  symptom. 
Hemorrhages  into  the  skin  arc  of  compara- 
tively infrequent  occurrence. 

Scurvy  uncomplicated  is  not  accompanied 
by  fever.  Acute  articular  rheumatism  is 
always  accompanied  by  fever.  Rheuma- 
tism is  rare  in  children  under  two  years  of 


Rheumatism  261 

age ;  scurvy  is  rare  in  children  over  two  years 
of  age.  There  is  no  excuse  for  an  error  in 
diagnosis  between  the  two  affections. 

The  treatment  is:  fresh  cows'  milk,  beef 
juice,  and  orange  juice.  For  a  child  one 
year  of  age  the  juice  of  one  orange  should 
be  given  daily.  Under  proper  treatment 
the  average  case  will  be  well  in  a  week  or 
ten  days,  improvement  being  noticed  in 
from  twenty-four  to  forty-eight  hours  after 
beginning  the  treatment. 

RHEUMATISM 

Rheumatism  is  a  disease  of  very  grave 
import  and  of  rather  frequent  occurrence 
among  children  after  the  third  year.  Under 
the  second  year  it  is  of  the  rarest  occurrence. 
At  this  age  scurvy  is  frequently  diagnosed 
as  rheumatism.  It  may  appear  in  all  de- 
grees of  seventy.  The  mild  attacks  are 
often  so  slight  that  a  physician  is  not  con- 
sulted and  the  diagnosis  of  rheumatism 
never  made.  Such  eases  are  often  mistaken 
for  sprains  and  so-called  "growing-pains." 
Aside  from  this  mild  type  we  have  the  disease 
in  all  degrees  of  severitv.  The  severe  artic- 


262  Grippe 

ular  form  known  as  inflammatory  rheu- 
matism, is  that  in  which  the  child,  with  high 
fever,  reddened,  swollen  joints,  dreads  your 
approach  to  the  bedside  and  begs  you  not 
to  touch  him.  There  can  be  no  attack  of 
rheumatism  so  mild  that  it  should  be  ignored. 
Ever}'  child  ill  with  this  disease  is  in  danger 
of  heart  complications  which  may  make  him 
an  invalid  for  life.  Probably  four-fifths  of 
the  cases  of  valvular  heart  disease  in  adults 
are  due  to  attacks  of  rheumatism  during 
childhood,  and  in  many  instances  the  disease 
of  the  heart  is  not  recognized  until  long  after 
the  rheumatic  attack.  In  every  case  of 
rheumatism  the  heart  should  be  examined 
and  properly  treated.  Heart  involvement 
is  as  liable  to  develop  in  the  mild  as  in  the 
severe  attacks.  In  some  cases  it  is  the  only 
evidence  of  the  presence  of  rheumatism. 
Children  of  rheumatic  parentages  and  those 
who  show  rheumatic  tendencies  should  be 
given  a  very  low  sugar  diet  with  red  meat 
not  over  three  times  a  week. 

GRIPPE 
Grippe  is  a  disease  very  prevalent  among 


Grippe  203 

children  during  the  colder  months.  It  is  due 
to  a  micro-organism  which  is  usually  taken 
into  the  system  with  the  inspired  air.  There 
are  four  types  of  the  disease  to  be  seen  in 
children. 

In  the  most  common  type  the  respiratory 
passages  are  the  parts  chiefly  involved.  The 
symptoms  resemble  in  some  respects  those 
of  a  common  cold.  There  is  running  at  the 
nose,  cough,  sore  throat,  and,  generally, 
bronchitis.  There  is  a  higher  fever,  how- 
ever, than  can  be  explained  by  the  catarrhal 
symptoms,  greater  muscular  weakness,  and 
greater  prostration.  If  uncomplicated,  the 
disease  usually  rims  its  course  in  from  five 
to  eight  days.  The  complications  to  be  es- 
pecially dreaded  are  bronchitis,  pneumonia, 
and  otitis. 

The  next  most  frequent  type  of  grippe  is 
the  muscular.  There  are  fever,  headache, 
loss  of  appetite,  prostration,  and  great  mus- 
cular weakness.  There  is  little  or  no  involve- 
ment of  the  respiratory  tract. 

The  third  type  includes  the  cases  in  which 
the  intestinal  symptoms  predominate.  1 
saw  about  twenty  of  these  cases  during 
the  winter  of  iS<;o-()T.  The  children  were 


264  Grippe 

taken  suddenly  with  fever,  prostration,  and 
diarrhoea  which  was  very  hard  to  control. 
There  were  from  eight  to  sixteen  green, 
watery  passages  daily,  containing  a  moderate 
amount  of  mucus,  streaked  with  blood. 
There  were  also  slight  cough  and  coryza, 
with  considerable  congestion  of  the  throat. 

In  the  fourth  type  the  nervous  system 
is  chiefly  affected.  These  patients  have  the 
fever  and  muscular  soreness  common  to  all 
varieties,  with  the  prominent  symptom- 
excessive  irritability.  In  some  cases  there 
seems  to  be  almost  entire  loss  of  self-control. 
The  patients  are  peevish,  fretful,  depressed 
and  hysterical  by  turn.  They  cannot  1  ear 
the  slightest  noise,  and  sleep  only  when  under 
the  influence  of  drugs. 

The  severe  cases,  however,  have  two 
symptoms  common  to  all--  fever  and  intense 
prostration;  prostration  and  weakness  out 
ot  propor' ion  to  all  objective  symptoms  are 
the  peculiar  characteristics  of  grippe.  I 
have  lost  two  patients  aged,  respectively, 
three  and  four  months,  in  both  of  which  the 
system  was  completely  overwhelmed  by  the 
virulence  (A  the  grippe  ]oV>"..  Doth  chil- 
dren died  in  less  than  twenty-four  hours, 


Convulsions  265 

apparently  from  exhaustion.  Post-mortem 
examination  failed  to  detect  in  either  case 
any  organic  change  sufficient  to  cause  death. 
A  very  unpleasant  feature  of  grippe  is  the 
wretched  physical  condition  in  which  the 
patient  is  often  left  after  the  acute  symptoms 
have  disappeared.  Weeks  of  the  most  care- 
ful treatment  will  frequently  be  required 
to  restore  his  previous  good  health.  There 
is  no  specific  treatment  for  this  disease. 
Every  case  must  be  treated  according  to 
the  symptoms  presented.  For  those  which 
fail  to  make  prompt  recovery,  a  change  of 
climate  should  be  advised.  Many  of  my 
patients  have  done  surprisingly  well  at 
Lakewood,  or  at  Atlantic  City. 

CONVULSIONS 

A  convulsion  is  a  temporary  loss  of 
consciousness,  associated  with  rhythmical 
contractions  of  various  muscles  of  the  body. 
Rachitic,  delicate  children,  and  those  suf- 
fering from  malnutrition  in  any  form  are 
predisposed  to  convulsions.  Disturbances  in 
the  gastro-intestinal  tract,  due  to  errors  in 
feeding,  have  been  the'  cause  in  ninetv-five 


266  Convulsions 

per  cent,  of  my  cases.  Nearly  all  were  seen 
among  the  badly  bottle-fed  or  in  those 
beyond  the  bottle  age  who  had  been  given 
food  unsuited  to  their  years.  I  have  fre- 
quently known  seizures  to  follow  an  unusual 
indulgence  in  cake,  pie,  or  fruit.  Exces- 
sively high  fever  may  be  a  cause  of  con- 
vulsions. Pneumonia,  meningitis,  and 
contagious  diseases  are  sometimes  ushered 
in  by  convulsions.  Heat  prostration  and 
worms  may  be  mentioned  as  infrequent 
causes.  A  patient  of  mine, — a  boy  three 
years  old,— had  repeated  convulsions  until 
he  was  relieved  of  forty-three  large  round 
worms.  According  to  my  observation,  den- 
tition is  rarely  an  immediate  cause.  The 
dentition  period  covers  eighteen  months, 
and  children  often  have  convulsions  during 
this  time;  a  thorough  examination  of  the 
patient,  however,  will  usually  reveal  the 
seat  of  the  trouble  in  the  intestinal  canal 
or  stomach.  Dentition  may  indirectly  be  a 
factor.  A  few  years  ago  a  mother  insisted 
that  I  should  lance  the  healthy  gums  of  a 
girl  eighteen  months  of  age,  who  repeatedly 
had  convulsions.  This  I  refused  to  do.  and 
ordered,  instead,  two  teaspoon fuls  of  castor- 


Convulsions  267 

oil.  The  child  passed  one-quarter  of  a  par- 
tially masticated  orange  and  the  convulsions 
ceased. 

When  a  child  is  attacked,  prompt  action 
is  necessary.  The  family  physician  should 
be  sent  for  and  the  patient  placed  at  once  in 
a  mustard  bath  at  a  temperature  of  105°  F. ; 
an  even  tablespoonful  of  mustard  should  be 
added  to  five  gallons  of  water.  The  patient 
should  not  be  allowed  to  remain  in  the  bath 
over  ten  minutes,  when  he  should  be  removed 
and  dried  vigorously.  If  possible,  the  child's 
temperature  should  be  taken  while  in  the 
bath,  and  if  above  102°  F.  (in  convulsions 
it  usually  ranges  between  104°  and  106°  F.) 
the  temperature  of  the  water  should  be  low- 
ered to  75°  or  80°  F.  by  the  addition  of  ice 
or  cold  water.  Watch  the  effect  of  the  cool- 
ing of  the  bath  upon  the  child's  temperature, 
and  when  it  is  reduced  to  101°  F.,  remove 
him.  The  temperature  in  convulsions  should 
always  be  noted.  To  my  mind  the  high 
fever  has  oftentimes  a  great  deal  to  do  with 
the  seizure.  Xot  long  since  I  was  called  to 
see  a  child  in  convulsions.  Upon  my  arrival 
I  learned  that  he  had  been  put  into  a  hot 
bath  at  110°  P.,  and  kept  there  fifteen 


268  Convulsions 

minutes,  but  the  child  showed  no  signs  of 
improvement.  The  temperature  was  taken 
while  in  the  bath,  and  registered  m°  F., 
as  high  as  the  thermometer  would  register. 
In  this  case  the  hot  bath  was  the  worst 
means  of  treatment  that  could  be  devised. 
There  is  no  advantage  in  making  the  water 
hotter  than  105°  F.  In  the  bath,  or  imme- 
diately upon  removal,  give  an  enema  of  soap 
and  water  so  as  to  insure  a  movement  of 
the  bowels  as  soon  as  possible.  As  soon  as 
the  child  can  swallow,  one  or  two  teaspoon- 
fuls  of  castor-oil  should  be  given.  If  it  is 
known  that  the  child  has  taken  something 
indigestible,  a  teaspoonful  of  syrup  of  ipecac 
should  be  given,  and  repealed  in  twenty 
minutes  if  vomiting  does  not  follow.  The 
convulsion  is  very  apt  to  be  repeated  if  the 
cause  is  not  removed.  The  patient  should 
not  be  held  on  the  lap.  He  should  be  placed 
in  his  crib  and  kept  very  quiet.  Cold  cloths 
should  be  applied  to  the  head  and  a  hot- 
water  bag  to  the  feet.  Xo  solid  food  or 
milk  should  be  given  for  t \veniy-four  hours; 
broths  and  barley-water  should  constitute 
the  diet.  During  the  next  lV\v  days  there 
should  be  no  excitement,  and  the  physician's 


Colic  269 

orders  regarding  medication  and  diet  should 
be  carefully  carried  out. 

COLIC 

There  are  few  children  who  reach  the  age 
of  one  year  without  having  suffered  from 
colic.  Infants  in  the  earliest  months  of  life 
are  particularly  susceptible  to  such  attacks. 
The  majority  of  cases  are  seen  in  children 
under  five  months  of  age,  although  the  seiz- 
ures may  continue  until  a  much  later  period. 
During  the  attack  the  child  cries  violently, 
becomes  red  in  the  face,  clinches  its  fists, 
draws  up  its  legs,  doubles  up  its  body,  and 
straightens  out  again.  The  abdomen  is 
hard,  often  distended,  and  the  hands  and 
feet  are  cold.  The  child  rests  a  few  moments 
and  cries  again.  Often  all  attempts  at  com- 
forting him  fail.  An  attack  may  continue 
from  a  few  moments  to  an  hour  or  more, 
perhaps  until  the  child  sleeps  from  exhaus- 
tion. I  have  had  children  brought  to  me 
for  treatment  who  were  so  hoarse  from  crying 
that  they  could  scarcely  utter  a  sound.  There 
may  be  several  attacks  a  day  after  the  feed- 
ings or  they  may  not  appear  until  evening. 


270  Colic 

Afternoon  or  evening  colic  is  probably  most 
frequent.  These  cases  are  easily  explained. 
The  overtaxed  stomach  has  done  its  work 
fairly  well  early  in  the  day,  but  as  the  im- 
proper, frequent  feedings  follow,  it  becomes 
tired  and  refuses  to  work  "overtime."  Dur- 
ing the  night  some  rest  is  obtained,  but  the 
following  day  the  entire  programme  is  re- 
peated. So-called  colicky  children  are  often 
otherwise  perfectly  well.  If  the  trouble  is 
not  particularly  severe,  they  may  be  well- 
nourished  and  well-behaved  babies  when 
not  in  pain.  In  the  severe  cases  there  is  apt 
to  be  evidence  of  marked  malnutrition.  It 
is  often  remarked  that  "a  baby  must  do 
just  so  much  crying,"  and  nothing  is  done 
to  relieve  it.  If  one  baby  cries  more  than 
another  it  is  because  he  suffers  more.  A 
baby  rarely  cries  unless  he  is  uncomfortable 
or  in  pain,  lie  may  cry  while  his  clothing 
is  being  changed  because  it  disturbs  him; 
he  will  cry  from  cold,  hunger,  from  the  effects 
of  a  misdirected  pin,  or  from  pain  of  any 
nature,  but  never  without  any  reason.  The 
general  tendency  of  the  child  is  to  play,  to 
smile  and  be  happy.  When  this  is  not  the 
case  something  is  wrong. 


Colic  271 

Colic  in  every  instance  means  indigestion. 
It  means  that,  whether  breast-fed  or  bottle- 
fed,  the  food  is  not  suitable, — is  not  adapted 
to  the  child's  digestive  powers,  or  not  prop- 
erly given.  The  child  who  suffers  from 
habitual  colic  is  usually  constipated.  It 
has  been  my  experience  that  the  chief  error 
in  the  diet  causing  the  colic  was  the  excess 
of  the  proteid — the  curd-forming  element  in 
the  milk.  It  is  thus  practically  useless  to 
give  carminatives  and  soothing  syrups,  and 
other  remedies  of  a  sedative  nature,  except- 
ing for  the  immediate  effects.  Whatever  error 
may  exist  in  the  feeding  must  be  corrected. 
If  the  patient  is  a  breast-baby  we  must  treat 
the  mother, — the  source  of  the  child's  nour- 
ishment. Nursing  mothers  of  colicky  babies 
are  usually  of  sedentary  habits,  hearty  eaters, 
and  constipated.  Our  first  step  must  be 
to  cure  the  constipation  of  the  mother.  She 
should  have  one  full,  free  passage  from  the 
bowels  daily.  She  should  exercise  in  mod- 
eration in  the  open  air:  a  walk  of  an  hour 
or  two  in  the  morning,  and  an  hour  in  the 
afternoon,  will  be  most  beneficial.  Her  diet 
should  consist  of  fresh  meat,  poultry,  iish, 
cereals,  soups,  baked  potato,  green  \vge- 


272  Colic 

tables,  and  stewed  fruit.  Coffee  may  be 
taken  in  moderation;  milk,  cocoa,  chocolate, 
and  water  may  be  taken  freely.  A  nursing 
mother  should  drink  no  tea.  It  is  a  popular 
idea  that  tea  is  a  very  necessary  article  for 
the  nursing  mother.  Hardly  a  week  passes 
but  I  hear  from  the  out-patient  mother  of 
a  sick  breast-baby  that  she  is  drinking  from 
one  to  two  gallons  of  tea  a  day.  The  tea  is 
kept  "on  the  back  of  the  stove,"  so  as  to  be 
ready  for  use  at  any  time.  I  have  relieved 
many  cases  of  colic  in  the  child  simply  by 
curing  the  mother's  constipation  and  regu- 
lating her  diet. 

Menstruation  often  causes  temporary  at- 
tacks of  colic  and  other  digestive  disturb- 
ances in  the  child.  Fright,  anger,  worry, 
or  anything  in  the  nature  of  a  shock  in  the 
mother  will  often  seriously  affect  the  child's 
digestion.  In  short,  when  the  nursing  child 
suffers  thus  from  digestive  derangements, 
the  error,  nine  times  out  of  ten,  rests  with 
the  mother.  The  trouble  is  rarely  with  the 
child. 

As  previously  stated,  habitual  colic  in 
the  bottle-fed  tells  us  thai  we  are  not  giving 
the  child  a  suitaMe  fond,  or  lliat  we  are 


Colic  2  73 

not  giving  a  suitable  food  properly.  The 
food  as  a  whole  may  be  too  strong  or  too 
weak.  It  may  be  given  too  frequently. 
If  cows'  milk  is  the  diet,  the  error  is  often 
due  to  improper  modification.  The  proteid 
will  usually  be  found  in  excess ;  not  in  excess, 
perhaps,  for  the  average  child,  but  in  excess 
for  the  patient  in  question.  There  can  be 
no  set  rules  for  feeding  or  definite  formula? 
for  various  ages  that  are  infallible.  The 
food  of  artificially  fed  children  must  be 
adapted  to  meet  their  individual  require- 
ments. The  treatment  of  habitual  colic  in 
the  bottle-fed  consists  in  rendering  the  food 
suitable. 

For  the  relief  of  immediate  attacks,  an 
injection  of  from  six  to  eight  ounces  of  water 
at  no0  P.,  to  which  one-half  teaspoonful  of 
salt  has  been  added,  will  often  be  of  service. 
Five  to  eight  drops  of  gin  in  a  teaspoonful  of 
warm  water,  by  mouth,  is  sometimes  useful. 
Two-drop  doses  of  Hoffmann's  Anodyne  in 
two  teaspoonfuls  of  hot  water  will  frequently 
cut  short  a  severe  attack.  Both  the  gin  and 
the  anodyne  may  be  repeated  in  one-half 
hour  if  relief  is  not  obtained.  If  the  attack 
is  prolonged,  a  hot-water  bag  should  be 


274  Constipation 

placed  at  the  feet,  and  flannels  wrung  out  of 
hot  water  applied  to  the  abdomen.  Often- 
times, in  order  that  the  digestive  organs  may 
have  a  complete  rest,  it  is  advisable  to  dis- 
continue the  regular  food  for  a  few  hours, 
and  give  barley-water  as  a  substitute. 

CONSTIPATION 

Among  the  derangements  of  the  young, 
there  are  few  which  give  more  annoyance 
or  are  harder  to  manage  successfully  than 
constipation.  The  causes  of  the  trouble  are 
anatomical  and  dietetic.  The  comparatively 
long  large  intestine  folded  upon  itself  in 
thenarrow  pelvis  offers  an  obstruction  to  the 
free  passage  of  the  intestinal  contents.  The 
lack  of  development  of  the  muscular  struc- 
ture of  the  intestine  is  also  a  cause.  Deficient 
nerve  power,  due  to  lack  of  development  of 
the  sympathetic  nervous  system,  is  thought 
by  many  to  be  an  important  factor.  In  all 
probability  all  these  agents  may  be  regarded 
as  predisposing  causes  of  constipation.  The 
chief  cause  of  constipation,  however,  accord- 
ing to  my  observation,  is  the  proteid  (the 
curd)  in  the  child's  milk.  When  the  amount 


Constipation  275 

of  proteid  is  excessive, — a  higher  percentage 
than  normal, — the  child  will  be  constipated. 
A  child  fed  on  a  normal  proteid  with  a  low- 
fat  will  also  probably  become  constipated 
on  a  milk  perfectly  adapted,  because  of  the 
difficulty  of  digesting  cows'-milk  proteid,  or 
because  the  heating  of  the  milk  is  carried 
too  far. 

Management  in  the  breast-fed. — Among  the 
breast-fed,  the  dietetic  management  of  this 
disorder  is  difficult,  for  it  is  hard  to  change 
the  character  of  the  mother's  milk.  Much 
may  be  done,  however.  Inquiry  into  the 
daily  life  of  the  mother  will  usually  disclose 
sedentary  habits,  a  good  appetite,  a  fond- 
ness for  tea,  and,  probably,  constipation.  An 
examination  of  the  milk  of  these  mothers 
will  show  that  the  normal  proportions  of 
fat,  proteid,  and  sugar  are  not  maintained. 
The  percentage  of  proteid  is  usually  found 
to  be  higher  than  normal,  with  low  or  normal 
fat. 

The  first  step  in  the  treatment  is  the  regu- 
lation of  the  habits  of  the  mother.  The 
bowels  should  be  evacuated  daily,  with  a 
laxative,  if  necessary.  She  should  be  placed 
on  a  diet  of  fresh  meal,  fresh  vegetables,  and 


276  Constipation 

fruit.  A  malt  liquor  with  luncheon  or  dinner 
is  also  sometimes  recommended.  She  is 
instructed  to  take  at  least  three  hours'  exer- 
cise daily  in  the  open  air.  This  regime  will 
diminish  the  proteid  and  increase  the  fat  in 
her  milk,  and  not  only  relieve  constipation 
in  the  child,  but  insure  better  nourishment 
and  a  later  weaning  than  would  otherwise 
be  possible.  The  treatment  of  the  mother  is 
all  that  is  necessary  in  a  considerable  num- 
ber of  cases,  but  when  this  fails,  the  child 
demands  attention. 

In  treating  the  child  my  first  step  is  to 
give  cream;  not  cream  purchased  as  such, 
but  cream  which  rises  upon  the  best  milk 
obtainable.  I  give  from  one-half  to  two 
teaspoon fuls  in  quite  warm  water  imme- 
diately before  nursing.  The  use  of  the  gluten 
suppository  at  the  same  hour  for  several 
consecutive  days  will  do  much  to  establish 
the  habit  of  a  passage  at  a  regular  hour  each 
day. 

In  case  the  cream  docs  not  agree  with  the 
child  or  is  ineffective,  pure  cod-liver  oil — 
fifteen  to  thirty  drops  three  or  four  times 
a  day,  or  one  teaspoonful  of  sweet  oil  two 
or  three  times  a  day-— may  prove  beneficial. 


Constipation  277 

When  these  measures  fail,  as  they  will  in  a 
small  number  of  cases,  further  medication 
will  be  required. 

Management  in  the  bottle-fed. — The  treat-, 
ment  of  bottle-fed  and  "runabout"  children 
is  much  easier  and  the  results  more  satis- 
factory. It  is,  moreover,  very  simple,  and 
resolves  itself  largely  into  a  manipulation 
of  the  fat  and  the  proteid.  Given  a  bottle- 
fed  child,  six  months  of  age,  suffering  from 
obstinate  constipation,  and  the  proteid 
should  at  once  be  cut  down  to  a  minimum 
by  prescribing  a  cream,  water,  and  sugar 
mixture.  This  should  be  given  raw,  if  prac- 
ticable. A  i6-per-cent.  cream  is  desired. 
Allow  the  milk  which  is  delivered  in  bottles 
at  about  six  o'clock  in  the  morning  to  remain 
in  the  refrigerator  until  noon,  when  all  the 
cream  is  removed.  If  the  milk  is  good,  the 
cream  will  contain  approximately  16  per 
cent,  of  fat;  if  it  deviates  from  this  figure, 
the  percentage  will  probably  be  lower.  I 
use  the  pint  (sixteen  ounces)  for  a  standard. 
If  we  mix  one  ounce  of  this  i6-per-cent. 
cream  with  fifteen  ounces  of  water,  we  will 
have  a  i-per-cent.  fat  mixture.  If  two  ounces 
of  cream  are  mixed  with  fourteen  ounces  of 


278  Constipation 

water,  a  2-per-cent.  fat  mixture  will  result; 
if  four  ounces  of  cream  with  twelve  ounces 
of  water,  we  will  have  a  4-per-cent.  fat  mix- 
ture. But  our  i6-per-cent.  cream  contains 
more  than  fat.  It  contains  also,  approxi- 
mately, 3.2  per  cent,  proteid  and  3.2  per  cent, 
sugar.  If,  then,  we  are  to  prepare  a  food 
for  this  six  months'  constipated  baby,  we 
need  a  high  fat  mixture, — four  per  cent.,— 
with  a  low  proteid.  In  order  to  obtain  it, 
we  use  four  ounces  of  cream  and  twelve 
ounces  of  water.  This,  as  will  easily  be 
seen,  will  furnish  us  a  4-per-cent.  fat,  8-per- 
cent, proteid,  and  8-tenths-per-cent.  sugar. 
The  fat  is  as  high  as  we  wish  it,  the  proteid 
low  where  it  ought  to  be,  but  the  sugar  is 
too  low,  and  this  we  increase  by  the  ad- 
dition of  milk  sugar  or  cane  sugar. 

A  word  about  the  low  proteid — .8  of  one 
per  cent.  Compared  with  the  mother's  milk 
it  is  low,  but  we  must  remember  that  in 
our  modifications  we  are  not  dealing  with 
mothers'  milk.  In  many  cases  it  is  unwise 
to  attempt  to  give  as  high  a  protcid  as  that 
contained  in  mothers'  milk,  for  the  reason 
that  it  is  more  difficult  of  digestion,  and, 
by  reason  of  its  higher  nutritive  properties, 


Constipation  279 

it  is  not  required.  In  case  the  reduction 
of  the  proteid  is  impracticable,  or  does  not 
furnish  relief,  I  add  to  each  feeding  of  the 
cream  or  milk  mixture  one  or  two  teaspoon- 
fuls  of  Mellin's  food  or  malted  milk,  which 
will  often  act  as  a  satisfactory  laxative. 
One  feeding  daily  of  malted  milk,  which 
replaces  the  customary  feeding,  is  another 
means  of  relieving  constipation  in  the  bottle- 
fed.  In  older  children, — eight  to  twelve 
months  of  age, — cream  diluted  with  water 
is  often  given  with  oatmeal  jelly, — one  or 
two  tablespoonfuls  to  each  feeding.  It  is 
extremely  rare  for  a  case  to  resist  this  treat- 
ment, and  when  it  happens  I  usually  find 
the  stool  soft  when  voided,  deficient  peri- 
stalsis being,  doubtless,  the  cause  of  con- 
stipation. In  such  cases  medication  is 
required.  The  sweet  oil  as  advised  for  the 
breast-fed  may  also  be  used  here. 

Management  in  older  children. — In  "run- 
about" children  the  use  of  cream  and  water 
mixtures,  rare  meat,  green  vegetables,  stewed 
fruit,  zwieback,  and  bran  biscuit  renders 
the  management  of  constipation  exceedingly 
simple.  The  meals  must  be  given  at  regular 
intervals,  and  crackers  and  white  bread 


2  So  Constipation 

excluded.  Bran  biscuit  from  Stanford's, 
Street  and  Broadway,  New  York,  and  whole 
wheaten  bread  may  be  used  with  advantage. 
The  more  the  milk  is  heated  the  greater  its 
constipating  effects. 

It  is  our  hope  in  treating  constipation  to 
relieve  the  patient  by  the  dietetic  measures 
above  suggested.  When  these  fail,  we  must 
resort  to  other  means.  Enemas  and  sup- 
positories may  be  used  occasionally,  but 
the  child  should  not  become  accustomed  to 
them.  In  the  severe  cases  which  resist  die- 
tetic treatment,  the  outlook  for  an  early 
recovery  is  not  promising.  In  such  cases 
the  use  of  an  enema  of  olive  oil  at  bedtime 
has  proven  very  satisfactory.  A  small 
amount  of  the  oil,  two  to  three  ounces,  is 
introduced  through  a  large  catheter,  No.  18 
American  (male),  which  is  inserted  ten  or 
twelve  inches,  the  catheter  being  attached 
to  a  bulb  syringe  with  a  capacity  of  six  ounces 
(see  Fig.  18).  An  evacuation  is  not  desired 
until  the  following  morning,  when  the  child 
is  placed  at  stool  after  his  breakfast  and  al- 
lowed to  remain  fifteen  minutes.  If  no  evacu- 
ation occurs  at  the  end  of  this  time,  a  slight 
stimula'ion  in  tin-  use  of  a  suppositorv  or 


Constipation  281 

soap-suds  may  he  used  to  bring  it  about. 
In  a  comparatively  few  days  usually  the 
morning  evacuation  takes  place  without 
assistance.  The  oil  should  be  continued 


FIG.     IS.       THE    Bl'I.B    SYRINGE 

for  several  days,  when  it  may  be  omitted 
one  night  in  seven.  When  an  evacuation 
follows  the  next  morning,  it  may  be  omit- 
U'd  one  night  in  five.  In  this  way  the 
oil  may  be  gradually  lessened  until  it  is 
no  longer  required.  In  some  children  a 
small  amount  of  the  oil  will  be  passed 
during  the  night.  These  should  wear  a 
napkin. 


282  Vaccination 

VACCINATION 

Every  baby  in  fair  health  should  be  vac- 
cinated not  later  than  the  third  month— 
before  any  trouble  incident  to  dentition 
may  arise;  for  the  younger  the  child,  the  less 
the  constitutional  disturbance.  Vaccina- 
tion in  a  child  two  to  three  months  of  age 
causes  practically  no  illness  whatever.  Both 
sexes  should  be  vaccinated  on  the  outer 
side  of  the  calf  of  the  leg:  girls,  because  the 
resulting  scar  on  the  arm  may  be  regarded, 
in  later  life,  as  a  disfigurement;  and  both 
boys  and  girls,  because  when  the  sore  is  on 
the  leg  it  is  more  easily  cared  for.  In  dress- 
ing and  undressing  a  child,  the  arm  has  to 
be  manipulated  to  a  considerable  extent, 
thus  causing  more  or  less  discomfort.  The 
wound  should  be  kept  covered  with  a  ster- 
ilized gauze  bandage  until  the  crust  falls, 
leaving  the  dry  pink  skin  underneath.  Tub 
bathing  should  be  discontinued  until  this 
takes  place. 

Vaccination  shields  are  all  worse  than 
useless;  they  are  often  positively  harmful, 
for  they  usually  become  displaced  and  may 
irritate  and  infect  the  sore.  \Vhen  unpleas- 


Vaccination  283 

ant  results  follow  the  vaccination,  the  virus 
is  rarely  at  fault.  The  infection  is  usually 
due  to  carelessness  or  to  uncleanliness  in 
the  treatment  of  the  wound. 

Vaccination  will  always  be  considered  by 
people  who  enjoy  the  possession  of  an  ordi- 
nary amount  of  knowledge  and  a  moderate 
amount  of  common-sense  as  one  of  the  great- 
est discoveries  of  medical  science.  Since  its 
discovery  by  Jenner,  as  statistics  show,  mil- 
lions of  lives  have  been  saved  by  vaccination. 
It  would  seem  strange  that  one  should  feel 
it  necessary  to  speak  in  defence  of  a  measure 
which  has  been  of  such  incalculable  value 
to  the  human  race,  but  there  are  a  noisy  lot 
of  mentally  incompetent  anti-vaccinationists, 
who  are  not  without  influence  among  their 
kind  and  the  otherwise  ignorant,  upon  whom 
the  following  statistics  by  Allen  (Pediatrics, 
February,  1900)  would  produce  no  effect. 

In  1871,  Germany  lost  one  hundred  and 
forty-three  thousand  lives  by  smallpox;  in 
1874,  a  law  was  enacted  making  vaccination 
obligatory  during  the  iirst  year  of  life  and 
compelling  its  repetition  during  the  tenth 
year.  The  result  was  that  the  disease  almost 
entirely  disappeared.  At  the  present  time 


284  Bed- Wetting 

the  loss  of  life  from  this  disease  throughout 
the  empire  is  scarcely  one  hundred  a  year. 
At  the  time  of  the  Franco-Prussian  War, 
the  entire  German  Army  was  re-vaccinated; 
while  in  the  French  Army,  vaccination  being 
optional,  comparatively  few  were  vaccinated. 
Both  armies  were  attacked  by  smallpox,  the 
French  losing  twenty-three  thousand  men, 
the  German,  two  hundred  and  seventy-eight. 
With  such  statistics  how  can  there  be  any 
plausibility  in  the  argument  of  the  anti- 
vaccinationists  ? 

BED- WETTING 

The  urine  is  voided  involuntarily  by  most 
children  until  well  into  the  second  year.  If 
the  child  is  carefully  trained,  the  function 
of  urination  may  be  under  perfect  control 
during  the  waking  hours  by  the  end  of  the 
first  year.  We  hear  now  and  then  of  a  child 
who  urinates  voluntarily  at  the  age  of  six 
months.  Such  children  are  rare.  The  urine 
is  passed  normally  during  sleep  until  the 
child  is  two  and  one-half  or  three  years  of 
age.  In  many  this  will  be  controlled  at  the 
end  of  the  second  year,  but  I  do  not  regard 


Bed-Wetting  285 

the  lack  of  control  as  an  abnormality  until 
the  third  year  is  reached.  If  the  urine  is 
passed  involuntarily  after  the  child  is  three 
years  old,  a  physician  should  be  consulted, 
not  necessarily  to  give  drugs,  but  to  instruct 
the  mother  as  to  the  diet  and  general  hygiene. 
Incontinence  of  urine  may  be  due  to  a 
great  variety  of  causes,  among  which  may 
be  mentioned  a  highly  acid  urine,  stone  in 
the  bladder,  which  is  of  comparatively  rare 
occurrence,  adenoids,  thread-worms,  con- 
stipation, inflammation  of  the  vulva  and 
vagina  in  girls,  and  tightly  adherent  foreskin 
in  boys.  By  far  the  greatest  number  of 
cases,  however,  are  due  to  a  lack  of  develop- 
ment of  the  nervous  system  and,  in  addition, 
a  bad  habit.  Not  infrequently  the  trouble 
is  caused  by  too  freely  indulging  in  water 
and  milk  late  in  the  afternoon  and  during 
the  night.  It  is  rarely  a  symptom  of  kidney 
or  bladder  disease.  The  relief  of  the  invet- 
erate bed-wetter  of  five  or  six  years  of  age 
is  often  most  difficult.  The  child  must  be 
examined  by  a  physician  to  determine  that 
there  is  no  local  cause  for  the  trouble.  If 
no  such  cause  is  found,  well-directed  medi- 
cation, with  the  mother's  co-operation,  will 


286  Bed-Wetting 

usually  relieve  the  patient,  although  it  may 
require  months  to  do  it.  In  the  cases  of  only 
occasional  bed-wetting,  and  with  younger 
patients,  the  mother  alone  can  often  accom- 
plish considerable.  No  water  or  milk  should 
be  given  after  four  o'clock  P.M.  The  child 
should  have  a  dry  supper,  for  which  I  would 
suggest  farina,  hominy,  or  rice,  any  of  which 
may  be  served  with  butter  and  a  little  sugar. 
If  the  child  will  not  take  the  cereals  without 
milk,  a  very  little  may  be  added.  This  with 
stewed  fruit  and  a  piece  of  bread  is  sufficient. 
The  child's  bedclothing  should  be  light,  and 
he  should  be  made  to  sleep  on  his  side,  not 
on  his  back.  In  order  to  prevent  the  child 
resting  on  his  back,  tie  a  piece  of  any  thin 
goods  about  the  body,  with  a  large  knot 
between  the  shoulders.  The  child  should 
always  be  taken  up  at  ten  or  eleven  o'clock 
and  made  to  urinate. 

If  there  is  phimosis,  vaginitis,  thread- 
worms, or  any  local  disorders,  treatment 
of  the  local  conditions  may  effect  a  cure. 

A  few  bed-wetting  children  are  troubled 
with  incontinence  during  the  day  as  well. 
There  is  a  constant  leakage1,  the  clothing 
bring  wet  the  greater  part  of  the  time.  The 


Care  of  the  Genitals  287 

management  of  these  cases,  however,  differs 
in  no  respect  from  that  advised  for  those  first 
mentioned,  except  in  the  matter  of  medica- 
tion, which  can  only  be  carried  out  by  a 
physician. 

CARE  OF  THE  GENITALS 

PAINFUL    MICTURITION,    CIRCUMCISION 

In  girls  very  little  care  of  the  genitals  is 
required  other  than  cleanliness.  The  parts 
should  be  washed  in  boiled  water  and  Castile 
soap  once  a  day.  Sponges  should  not  be 
used.  Soft  old  linen  is  far  better,  and  after 
once  using  it  should  be  burned.  A  sponge 
is  never  clean  after  it  has  once  been  used, 
and  should  have  no  place  in  the  nursery 
outfit.  A  nurse  should  never  begin  the 
baby's  bath  until  she  has  thoroughly  cleansed 
her  own  hands  with  soap  and  hot  water. 
After  cleansing,  the  parts  should  be  dusted 
thoroughly  with  the  following  powder:  bo- 
racic  acid  ten  grains,  powdered  starch  and 
oxide  of  zinc  each  one-half  ounce. 

With  boys  more  attention  is  required. 
The  normal  condition,  a  free  foreskin,  non- 


288          Care  of  the  Genitals 

adherent  to  the  glans  penis,  is  necessary 
for  his  comfort  and  health.  It  should  be 
stripped  back  once  a  day  and  the  parts 
washed  very  gently  with  Castile  soap  and 
warm  water,  dried  with  absorbent  cotton, 
and  a  bit  of  vaseline  applied.  In  the  ma- 
jority of  boys  the  foreskin  at  birth  is  tightly 
adherent  to  the  glans,  with  only  a  pin-hole 
opening.  Such  a  condition  is  one  of  much 
annoyance  to  the  child.  Secretions  which 
act  as  a  foreign  body  form  under  the  foreskin, 
producing  no  little  irritation,  drawing  the 
child's  attention  to  the  parts,  and  thus  often 
leading  directly  to  the  habit  of  masturbation. 
Inflammation  of  the  foreskin  and  urethra 
not  infrequently  follows  this  condition.  As 
a  result,  urination  is  painful  and  the  urine 
is  retained  until  the  child  cannot  pass  it. 
I  have  known  children  for  this  reason  to 
hold  their  urine  for  over  twenty-four  hours. 
In  two  cases  which  came  under  my  obser- 
vation, pus  formed  under  the  foreskin,  neces- 
sitating immediate  operation.  In  two  boys 
aged  about  two  years,  repeated  convulsions 
occurred,  for  which  no  reason  could  be 
assigned  other  than  the  irritation  caused 
by  the  tightly  adherent  foreskin  and  the 


Retention  of  Urine  289 

retained  secretions.  They  were  circum- 
cised, and  have  been  perfectly  well  during 
the  two  years  which  have  intervened.  Bed- 
wetting  is  often  a  direct  outcome  of  this 
trouble. 

Four  out  of  five  of  the  boys  who  come 
under  my  care  need  circumcision.  This 
does  not  mean  that  four  out  of  five  are  cir- 
cumcised, as  family  objections  are  often  hard 
to  overcome,  even  where  the  physician  is 
convinced  that  such  a  measure  would  be 
beneficial.  In  a  very  few  cases,  stretching 
and  retracting  the  foreskin  may  answer  every 
purpose.  But  such  cases  are  rarely  attended 
to  properly  afterward;  no  matter  how  care- 
ful the  instructions  given,  the  adhesions  are 
allowed  to  re-form,  and  in  a  short  time  all 
the  annoying  symptoms  return.  When  a 
child  is  properly  circumcised  he  is  relieved 
for  all  time. 

RETENTION  OF  URINE 

This  condition  often  greatly  alarms 
mothers.  In  girls,  the  most  frequent  cause 
is  pain  due  to  the  inflammation  of  the  ure- 
thra 1  orifice  and  the  adjoining  parts,  which 


290  Retention  of  Urine 

may  have  been  caused  either  by  excessive 
acidity  of  the  urine,  or  by  vaginitis.  Re- 
tention sometimes  results  from  taking  cold; 
high  fever  is  sometimes  a  cause,  and,  in 
some  instances,  no  cause  can  be  discovered. 
In  boys  the  retention  may  be  due  to  urc- 
thral  irritation  produced  by  excessive  acidity 
of  the  urine;  far  more  frequently,  however, 
the  trouble  is  caused  by  an  inflammation 
of  the  foreskin,  which  is  often  swollen  to 
three  or  four  times  its  normal  size.  In  these 
cases  the  orifice  of  the  urethra  will  usually 
be  found  red  and  swollen.  In  either  sex, 
if  there  is  retention  of  the  urine  for  over 
sixteen  hours,  place  the  child  in  a  tub  of 
warm  water  at  a  temperature  of  110°  F., 
and  often  urination  will  follow  immediately. 
Another  useful  method  of  treatment  con- 
sists in  the  application  to  the  parts  of  cloths 
wrung  out  of  hot  water.  Perhaps  the  best 
results  are  obtained  by  the  use  of  an  enema 
of  a  normal  salt  solution, — a  tcaspoonful  of 
salt  to  a  pint  of  water,-— at  a  temperature 
of  110°  F. ;  at  least  a  pint  should  be  used  for 
this  purpose  and  the  child  allowed  to  retain 
it  if  he  will.  This  treatment  rarely  fails. 
If  it  does,  the  doctor  must  use  the  catheter. 


Nose-Bleed  291 

The  swelling  of  the  parts  in  boys  is  best 
reduced  by  a  wet  dressing  of  a  saturated 
solution  of  boracic  acid,  which  is  applied 
on  old  linen  wrapped  around  the  parts  and 
changed  every  half-hour.  In  girls  a  simple 
pad  composed  of  several  layers  of  old  linen 
should  be  saturated  with  the  boracic  acid 
solution  and  similarly  applied,  the  dressing 
being  changed  every  hour,  and  the  parts 
gently  bathed  with  the  solution. 

NOSE-BLEED 

Nose-bleed  may  result  from  a  fall  or  blow, 
or  from  any  direct  injury  to  the  nose.  In 
most  instances,  however,  it  occurs  inde- 
pendently of  injury.  Adenoids  are  fre- 
quently a  cause  of  nose-bleed.  Small  ulcers 
often  form  on  the  nasal  septum  of  delicate, 
poorly-nourished  children,  and  give  rise  to 
most  obstinate  hemorrhage.  Habitual  and 
severe  nose-bleed,  particularly  from  one 
nostril,  is  usually  due  to  this  cause.  What- 
ever may  be  the  cause  of  the  hemorrhage 
the  immediate  management  must  be  the 
same.  The  child  should  sit  erect  and  the 
nose  be  firmly  compressed  for  twenty  min- 


292  Worms 

utes  between  the  thumb  and  finger.  The 
tips  of  the  thumb  and  finger  should  touch 
the  lower  portion  of  the  nasal  bones.  The 
application  of  ice  is  also  beneficial;  a  small 
piece  of  ice  being  wrapped  in  a  handkerchief 
and  held  against  the  nostril  from  which  the 
blood  is  flowing.  After  the  hemorrhage  has 
ceased,  continue  the  application  of  ice-cloths 
for  one-half  hour  and  watch  the  child  so  as 
to  prevent  his  blowing  the  nose.  If  the 
hemorrhage  is  severe,  or  if  slight  hemor- 
rhages are  repeated,  a  physician  must  be 
consulted. 

WORMS 


There  are  three  varieties  of  worms 
commonly  met  with  in  children:  the  round- 
worm,  the  thread- worm,  and  the  tape- 
worm. 

Round-worms  occur  most  frequently  in 
children  from  two  to  ten  years  of  age, 
although  no  age  is  exempt.  When  a  child 
j ticks  its  nose,  grinds  its  teeth  at  night,  sleeps 
poorly,  has  a  coated  tongue,  and  an  indiffer- 
nt  appetite,  it  is  supposed  by  the  older 
members  of  the  familv  to  have  '"worms." 


Worms  293 

These  symptoms  may  indicate  the  round- 
worms,  but  they  far  more  frequently  indicate 
a  too  close  acquaintance  with  gingerbread 
and  jam  and  other  cupboard,  between-meal 
indulgences.  Frequent  attacks  of  colic, 
constipation,  alternating  with  diarrhoea,  and 
convulsions  are,  in  my  judgment,  the  most 
reliable  symptoms  of  round-worms.  The 
only  positive  means  of  diagnosis,  however, 
is  the  discovery  of  the  worm  itself,  or  the 
presence  of  the  eggs  in  the  stools.  The 
round-worm  resembles  the  common  earth- 
worm. It  is  usually  from  five  to  nine  inches 
in  length  and  inhabits  the  small  intestine. 
Round-worms  are  seldom  seen  among  city 
children;  in  the  country,  however,  they  occur 
with  much  greater  frequency. 

Thread-worms  inhabit  the  lower  portion  of 
the  large  intestine,  and  in  appearance  are 
like  pieces  of  white  thread.  They  are  usually 
from  one-quarter  to  one-half  inch  in  length. 
They  are  very  frequently  seen  among  the 
children  of  the  tenements.  Occasionally 
they  occur  in  children  of  the  better  classes. 

The  chief  symptom  of  these  worms  is  an 
itching  or  irritation  about  the  anus.  The 
child  is  restless  and  sleeps  poorly.  In  girls 


294  Worms 

there  may  be  a  vaginal  discharge  due  to  the 
irritation  caused  by  the  worms,  which  have 
migrated  to  these  parts.  Frequently  the 
only  symptoms  of  discomfort  will  be  mani- 
fested when  the  child  is  put  to  bed.  He 
will  then  complain  of  a  biting,  burning 
sensation  in  the  rectum.  In  some,  the 
rectal  irritation  is  so  great  as  to  cause  very 
pronounced  nervous  symptoms. 

Some  years  ago  I  treated  a  six-year- 
old  girl  for  involuntary  movement  of  the 
arm  and  shoulders  somewhat  resembling 
St.  Vitus's  dance.  The  trouble  disappeared 
after  several  weeks'  treatment  for  the  thread- 
worms which  were  present  in  large  numbers. 
I  have  seen  many  cases  of  prolapse  of  the 
bowel  due  to  the  straining  which  was  caused 
by  the  irritant  action  of  the  worms.  In  both 
sexes  they  may  be  a  cause  of  bed-wetting 
and  in  girls  are  not  an  infrequent  cause  of 
masturbation.  In  some  instances  after 
treatment  the  worms  will  be  passed  in  great 
numbers  in  the  stools,  and  may  sometimes 
be  seen  adhering  to  the  skin  of  the  parts. 

Tape-worms  in  children  are  very  rarely 
seen  in  this  country.  I  have  seen  but  eight 
cases  among  nianv  thousands  of  children 


Cuts,  Bruises,  and  Sprains    295 

treated  during  the  past  seventeen  years. 
The  presence  of  the  tape-worm  is  indi- 
cated by  various  indefinite  manifestations. 
Constipation  alternating  with  diarrhoea  are 
prominent  symptoms.  The  child  is  often 
ravenously  hungry.  A  positive  diagnosis 
can  be  made  only  after  the  discharge  of 
segments  of  the  worm,  which  appear  like 
short  pieces  of  narrow  white  tape  linked 
together. 

The  diagnosis  and  treatment  of  worms 
in  the  children  of  the  household  appear  to 
be  a  jealously  guarded  function  of  the  good 
grandmother.  Young  mothers,  however, will 
do  well  to  have  the  family  physician  usurp 
this  prerogative. 

CUTS,  BRUISES,  AXD  SPRAINS 

Apparently  every  child  must  have  his 
share  of  cuts  and  bruises.  In  case  of  a  cut 
with  considerable  hemorrhage,  pressure  to 
the  injured  parts  with  cloths  saturated  with 
cold  water  will  aid  in  checking  the  hemor- 
rhage ;  later,  a  wet  dressing  of  a  saturated 
solution  of  boracic  acid  may  be  applied  on 
clean  muslin  or  clean  old  linen. 


296  Excitement 

If  there  is  a  bruise  with  much  swelling  to 
be  treated,  the  wet  dressing  with  the  boracic 
acid  solution  will  relieve  the  condition.  The 
dressing  may  be  continued  for  two  or  three 
hours  if  required,  the  bandages  being  fre- 
quently saturated  with  the  solution  in  order 
to  keep  them  wet  until  the  doctor  arrives. 

A  sprain  may  be  treated  in  a  similar  man- 
ner. The  wet  bandages  .should  be  bound 
around  the  injured  joint,  which,  if  a  lower 
extremity  is  involved,  is  kept  on  a  level  with 
the  body.  Severe  sprains,  cuts,  and  bruises 
require  medical  attention  at  the  earliest 
possible  moment. 

EXCITEMENT 

A  baby  should  not  be  subjected  to  excite- 
ment or  its  equivalent  -too  active  entertain- 
ment. The  nervous  system  of  an  infant  is 
in  such  an  undeveloped  state  that  what 
would  be  a  decided  tax  upon  it  cannot  be 
appreciated  by  adults,  who  arc1  often  appar- 
ently insensible  of  the  fact  that  children  are 
different  from  themselves. 

The  first  child  in  a  \vell-to-do  family  is 
usually  the  greatest  sufferer  from  superfluous 


Kissing  297 

attention, — being  a  source  of  unending  ad- 
miration on  the  part  of  the  family  and  friends. 
He  is  often  present  very  early  in  life  at 
all  important  functions.  Christmas,  Thanks- 
giving, birthday  celebrations,  and  afternoon 
teas  find  him  the  centre  of  attraction.  He 
is  handed  from  one  guest  to  another  and  is 
tossed  upon  various  angular  knees.  He 
is  kissed  by  lips  which  dare  touch  only 
those  who  cannot  protect  themselves.  He  is 
talked  to  with  a  very  loud  voice  in  a  very 
silly  manner  and  grimaces  horrible  to  witness 
are  made  at  him.  I  have  witnessed  such 
scenes,  and  have  treated  exhausted  infants 
who  required  medical  attention  after  the 
seance  was  over.  I  have,  indeed,  seen  in- 
fants thus  brought  to  the  verge  of  collapse. 
One  child  of  eleven  months  had  convulsions 
which  were  indirectly  due  to  fatigue  incident 
to  a  Thanksgiving  celebration. 

KISSING 

Such  a  topic  is  not  to  be  considered  out 
of  place  in  a  work  of  this  nature;  in  taking 
up  the  child's  management  in  all  its  details, 
it  is  mv  belief  that  a  few  remarks  on  this 


298  Kissing 

subject  are  perfectly  in  order.  Every  detail 
of  the  child's  daily  life  should  be  under  the 
oversight  of  the  physician,  and  if  he  is  to  do 
his  full  duty,  he  must  give  a  certain  amount 
of  voluntary,  unsought  advice.  A  custom 
concerning  which  he  will  not  be  consulted 
is  the  matter  of  that  most  unhygienic 
practice  of  kissing. 

A  child  should  never  be  kissed  on  the 
mouth,  and  this  is  a  standing  order  with  all 
my  patients.  I  have  known,  in  my  own 
private  practice,  of  instances  where  tuber- 
culosis, diphtheria,  and  syphilis  have  been 
communicated  from  the  diseased  adult  to 
the  innocent  child  by  this  disgusting  prac- 
tice. Neither  should  the  child's  hands  or 
fingers  be  kissed,  as  the  hands  and  fingers 
of  the  majority  of  babies  are  in  their  mouths 
many  times  an  hour.  If  baby  is  the  first 
one  that  has  graced  the  household,  and  must 
be  kissed,  this  can  be  accomplished  with  the 
least  damage  if  the  kiss  is  implanted  on 
the  head  or  forehead.  The  parents  must 
make  the  rule,  and  they  must  set  the  exam- 
ple by  adhering  to  it  themselves. 

Among  my  patients,  a  nurse  \vho  is  known 
to  have  kissed  the  child  is  punished  bv  dis- 


Sleep  299 

missal.  Because  an  adult  is  apparently  well 
is  no  excuse  for  this  indulgence.  Healthy 
adults  frequently  have  in  their  mouths  the 
germs  of  tuberculosis,  of  diphtheria,  and  of 
other  diseases,  and  never  suffer  from  their 
presence  because  they  are  strong  adults  with 
vigorous  mucous  membranes  which  do  not 
furnish  as  favorable  a  soil  for  the  growth 
and  development  of  pathogenic  bacteria  as 
do  the  more  delicate  mucous  membranes 
of  the  young.  It  is  criminal,  therefore,  to 
subject  the  child  to  such  dangers.  Scarlet 
fever,  measles,  and  whooping-cough  are  all 
most  readily  transmitted  at  the  beginning 
of  an  attack  through  the  close  contact  re- 
quired by  a  kiss. 

Kissing  should  not  be  allowed  among 
children.  Little  girls  are  very  prone  to 
follow  the  customs  of  their  mothers,  whether 
good  or  bad;  hence,  the  necessity  of  advice 
in  this  direction  will  be  impressed  upon  the 
parents  if  they  will  observe  the  interchange 
of  bacteria  which  takes  place  on  the  sailing 
or  arrival  of  anv  of  our  lar^c  ocean  steamers! 


The  infant  that  sleeps  well  is  almost  always 


300  Sleep 

a  normal,  well-fed  baby.  Irritability  and 
sleeplessness  are  associated  with  indigestion 
more  frequently  than  with  any  other  disorder. 
During  the  first  few  days  of  life  the  sleep, 
in  normal  conditions,  is  almost  unbroken, 
except  when  the  infant  is  fed.  During  the 
first  month  the  infant  sleeps  about  twenty- 
two  hours  out  of  every  twenty-four;  during 
the  second  and  third  months,  from  twenty 
to  twenty-two  hours.  At  the  sixth  month 
the  child  should  sleep  from  6  P.M.  to  6  A.M. 
without  interruption  other  than  for  feeding 
or  nursing,  which  need  cause  very  little 
disturbance.  At  this  age  there  should  be 
a  two-hour  nap  during  the  morning  and  a 
two-hour  nap  in  the  afternoon,  although  it 
is  not  well  to  have  the  baby  sleep  after  three 
o'clock  in  the  afternoon.  The  twelve-hour 
night  rest  should  be  continued  until  the  child 
is  six  years  of  age.  The  day  naps  will  grad- 
ually be  shortened  by  the  child.  At  one 
year  of  age,  one  hour  in  the  morning  and 
two  hours  in  the  afternoon  suffice.  From 
the  eighteenth  month  to  the  second  year,  the 
morning  nap  is  given  up.  Afternoon  rest 
for  at  least  one  and  one-half  hours  should 
be  continued  until  the  child  i  six  vears  of 


Sleep  301 

age,  and  longer  if  he  is  inclined  to  be  delicate. 
Regular  sleep  is  largely  a  matter  of  habit,  and 
if  the  infant  is  started  right,  with  suitable 
feedings  given  at  definite  times,  followed  by 
the  proper  period  of  sleep,  but  little  trouble 
will  be  experienced  with  sleeplessness.  When 
sleep  is  disturbed  and  broken,  it  means  bad 
habits,  unsuitable  food,  minor  forms  of  indi- 
gestion, or  positive  illness  of  some  kind. 
Sleep  is  important  for  purposes  of  growth 
not  only  in  early  infancy  but  throughout 
childhood.  Not  a  few  infants  form  habits 
of  sleeping  in  the  daytime  and  being  wakeful 
at  night.  This  is  best  remedied  by  keeping 
the  baby  awake  when  he  should  be,  during 
the  day,  by  entertainment  and  by  keeping 
him  in  a  well-lighted  room.  I  am  sure  that 
the  satisfactory  results  I  have  had  the  good 
fortune  to  achieve  in  the  treatment  of  sec- 
ondary malnutrition  and  anemia  have  been 
due  in  part  to  my  insistence  that  the  child 
sleep  in  a  quiet,  darkened  room  for  two  hours 
after  the  noonday  meal.  The  energy  ex- 
pended in  twelve  hours  by  an  active  child 
is  incalculable,  and  when  a  portion  of  this 
energy  is  reserved  and  the  body  fortified 
by  rest  and  sleep  during  the  middle  of  the 


302  Crying 

day,   it   means   a   greatly   diminished   daily 
expenditure  of  strength  units. 

CRYING 

It  is  well  for  the  young  infant  to  cry  a 
little  every  day.  Muscular  movements  in- 
volving a  greater  part  of  the  body  accompany 
the  act  of  crying  and  furnish  exercise.  Peri- 
stalsis is  increased,  as  is  often  evidenced  by 
a  movement  of  the  bowels  occurring  at  the 
time,  particularly  when  there  is  diarrhoea. 
In  crying,  deep  breathing  is  necessary,  the 
lungs  are  expanded,  and  the  blood  oxygen- 
ated. The  well  baby  cries  when  frightened, 
or  uncomfortable  from  hunger,  soiled  nap- 
kins, or  inflamed  buttocks.  He  cries  from 
pain,  from  heat,  from  cold,  from  unsuitable 
clothing,  and  during  difficult  evacuation  of 
the  bowels.  He  also  cries  when  displeased 
or  angry.  Authors  arc  prone  to  refer  to  the 
diagnostic  value  of  an  infant's  cry.  It  is 
my  belief  that  characteristic  cries  are  not 
to  be  depended  upon  sufficiently  to  give 
them  a  differential  diagnostic  dignity.  Chil- 
dren slightly  but  painfully  ill  may  cry  in- 
cessantly for  an  hour  or  two.  Thus,  with 


Cleanliness  303 

intestinal  colic,  where  the  cry  is  loud  and 
continuous  until  the  child  is  relieved  or  until 
he  falls  asleep  from  exhaustion.  Earache 
is  not  an  infrequent  cause.  The  habitual 
criers,  the  restless  and  vigorous  crying, 
whining  infants,  are  uncomfortable.  With 
very  few  exceptions  the  trouble  will  be  found 
in  the  intestinal  tract.  The  well-trained, 
normal  child,  whose  nourishment  is  suitable, 
is  seldom  troublesome.  When  well,  all  ba- 
bies are  naturally  good-natured  and  happy 
in  their  own  way.  Badly  managed,  spoiled 
infants  often  cry  vigorously  when  left  alone. 
When  attention  is  given  them,  when  they 
are  taken  up  and  talked  to,  the  crying  ceases. 
This  readily  tells  us  that  pain  or  discomfort 
was  not  an  element  in  causing  the  cry.  In 
these  infants,  discipline,  not  medication,  is 
needed.  The  management  of  the  habitual 
crier  involves  the  relief  of  the  condition 
which  causes  the  discomfort,  or  the  most 
rigid  discipline. 

CLEANLINESS 

Much  has  been  said  and  written  regarding 
the  necessity  of  cleanliness  so  far  as  the  child 


304        Cold  Hands  and  Feet 

is  concerned;  but  not  only  should  the  nurse 
and  mother  see  that  the  baby  is  clean;  they 
must  be  clean  themselves.  Immediately 
after  every  attention  to  the  napkin  the  hands 
should  be  washed  with  hot  water  and  soap 
and  a  stiff  brush.  This  cleansing  process 
must  be  repeated  before  the  preparation  of 
the  food  or  any  manipulation  of  the  feeding 
apparatus. 

The  child's  attendants  should  not  have 
decayed  or  neglected  teeth.  The  tooth- 
brush should  be  an  important  article  in  the 
outfit  of  every  nurse.  She  should  take  a 
tub-bath  or  sponge-bath  daily.  The  hands 
and  finger-nails  of  many  nursery-maids  will 
bear  watching. 

COLD  IIAXDS  AND  FEET 

The  hands  and  feet  of  the  infant  should 
never  be  cold  to  the  touch.  This  is  a  cause 
of  much  of  his  discomfort  and  restlessness. 
A  very  young  child  with  poor  circulation 
will  be  made  mueli  more  comfortable  by 
placing  a  hot-water  bag  at  his  feet.  Bottles 
filled  with  warm  water  and  wrapped  in 
flannel  will  keep  the  upper  extremities  warm. 


Foreign  Bodies  Swallowed    305 

In  using  the  hot-water  l>ags  and  bottles  be 
sure  that  the  water  is  not  too  hot.  Severe 
burning  accidents  have  resulted  from  care- 
lessness in  this  particular. 

An  excellent  means  of  keeping  premature 
or  delicate  babies  warm  is  in  the  use  of  the 
''Electrotherm"  (Fig.  12).  These  small 
heaters  are  attached  to  an  electric  fixture, 
like  a  drop-light.  A  convenient  size  is  from 
ten  to  fifteen  inches.  It  is  placed  between 
two  or  three  thicknesses  of  blankets,  upon 
which  the  infant  lies  in  its  basket  or  crib. 
The  degree  of  heat  can  be  regulated  accord- 
ing to  the  amount  of  electricity  turned  on. 

FOREIGN  BODIES  SWALLOWED 

The  child's  stomach  is  a  frequent  recep- 
tacle for  objects  for  which  it  was  never 
intended.  Pins,  buttons,  safety-pins,  small 
pieces  of  chalk,  pencils,  etc.,  often  find  their 
way  into  the  stomach  of  the  "runabout" 
child.  I  knew  one  child  to  swallow  an  open 
safety-pin,  and  another  to  swalloxv  a  stick- 
pin, the  head  of  which  was  a  small  four-leafed 
clover.  Both  children  passed  the  pins  with- 
out the  least  harm  resulting.  In  order  that 


306  Foreign  Bodies  in  Ear  and  Nose 

the  object  swallowed  may  not  injure  the 
child,  give  starchy  substances  in  large 
amount:  oatmeal,  potatoes,  corn-meal  mush, 
—substances  which  in  the  intestines  form 
a  semi-solid  mass  in  which  the  object  swal- 
lowed may  become  imbedded  and  carried 
forward.  These  cases  should  never  be  given 
castor-oil  or  any  other  laxative. 

FOREIGN  BODIES  IX  THE  EAR  AND 
NOSE 

This  subject  is  brought  to  the  attention  of 
mothers  to  warn  them  against  any  attempt 
at  the  removal  of  foreign  bodies  from  the 
nose  or  ears  of  one  of  their  children.  The 
means  often  thus  employed,  such  as  hair- 
pins, button-hooks,  etc.,  should  never  be 
used,  as  they  are  liable  to  do  much  harm. 
I  have  often  removed  shoe-buttons,  peas, 
beans,  pieces  of  coal,  and  pebbles  from  the 
nose,  and  have  had  trouble  only  with  those 
eases  in  which  some  member  of  the  family 
had  attempted  the  removal  with  the  result 
of  forcing  the  foreign  body  farther  into  the 
cavity.  \Vhen  the  foreign  body  is  in  the 
nose,  the  ehild,  if  old  enough,  can  sometimes 


Flies  and  Mosquitoes         307 

remove  the  obstacle  by  pressing  upon  the 
unobstructed  nostril  while  he  vigorously 
blows  the  nose.  When  this  does  not  succeed 
the  child  should  be  taken  to  a  physician. 

DANGERS   FROM   FLIES   AND   MOS- 
QUITOES 

The  windows  of  the  nursery  should  be 
screened  so  that  flies  and  mosquitoes  can- 
not enter.  When  out  of  doors  the  very 
young  child  should  be  protected  by  mos- 
quito-netting. Mosquitoes  severely  poison 
many  children,  and  are  of  especial  danger 
in  that  one  variety  is  capable  of  inoculat- 
ing the  child  with  malaria,  the  plasmodium 
malaria;  being  deposited  along  with  the  other 
poison. 

Flies,  in  addition  to  disturbing  sleep,  are 
a  source  of  much  danger  which  is  but  little 
appreciated.  The  fly  enters  the  nursery  and 
alights  on  the  nipple  of  the  nursing-bottle. 
This  may  take  place  while  the  child  is  resting 
for  a  second  or  two  during  his  meal,  as  flies 
are  very  fond  of  the  sweet  milk  which  may 
adhere  to  the  nipple;  or  the  fly  may  alight 
upon  the  child's  bread,  or  the  prepared  cereal, 


308  The  Doctor 

or  any  article  of  food,  particularly  if  there 
is  a  sweet  element  in  it.  The  last  place  the 
fly  rested  before  reaching  the  nursery  we 
never  know.  It  may  have  been  on  animal 
excrement,  or  tubercular  sputum,  or  the 
infectious  discharges  of  a  typhoid-fever 
patient.  In  this  way  the  flics'  feet  and  legs 
are  the  means  of  transporting  the  germs  of 
typl  old  fever  or  diphtheria.  Tuberculosis  is 
unquestionably  transferred  in  this  way  very 
frequently,  minor  ailments  with  still  greater 
frequency.  Flies  are  a  source  of  danger 
in  the  house,  and  should  be  driven  out  or 
destroyed. 

WHEN  TO  SEND  FOR  THE  DOCTOR 

This  question  is  easily  answered.  Send 
for  the  doctor  when  there  are  any  indica- 
tions of  illness  in  the  child  which  the  mother 
does  not  understand.  It  is  better  to  be 
overcautious  in  this  respect  than  to  join  the 
great  number  of  mothers  who  are  never  free 
from  the  bitter,  life-long  regret,  "The  child 
might  have  been  saved  had  he  been  treated 
in  time."  I  know  such  mothers. 

There    are    two    conditions    in    which    the 


Patent  Medicines  309 

mother  must  not  trust  herself  for  a  moment. 
These  are  summer  diarrhoea  and  sore  throat. 
"Only  a  summer  diarrhoea,"  and  "only  a 
sore  throat,"  and  "only  a  teething  diarr- 
hoea," have  sacrificed  the  lives  of  hundreds 
of  infants. 

Diphtheria  is  a  very  prevalent  disease, 
and  the  successful  treatment  of  it  requires 
that  the  child  be  seen  by  the  physician  at 
the  earliest  possible  moment.  So,  also,  with 
summer  diarrhoea.  I  have  seen  infants  die 
in  twelve  hours  with  the  disease.  Calling 
a  doctor  early  is  a  means  not  only  of  safety, 
but  of  economy.  In  the  correction  of  slight 
ailments,  grave  ones  are  avoided. 

PATENT  MEDICINES 

Patent  medicines  should  form  no  part 
of  the  nursery  outfit.  The  mother's  home 
remedies  should  all  be  approved  by  a  physi- 
cian. Cough  mixtures  and  soothing  syrups, 
the  advantages  of  which  are  so  faithfully 
portrayed  in  the  popular  magazines  and 
religious  periodicals,  are  often  very  harmful. 
Most  of  them  contain  alcohol,  opium,  or 
morphine.  Time  and  again  I  have  seen 


310  Summer  Resorts 

children  drugged  to  the  point  of  stupor  by 
these  remedies. 

SUMMER  RESORTS 

Where  to  take  the  child  for  the  summer 
is  a  vexed  question  which  arises  once  a  year 
in  many  households.  Several  years  of  obser- 
vation of  a  great  many  children  who  have 
spent  the  summer  out  of  town  have  led  me 
to  the  following  conclusions: 

1.  The    most    desirable    summer   outing: 
the  first  half  of  the  season  at  the  seashore, 
the    remainder    inland,    preferably    in    the 
mountains. 

2.  The    next    in    order    of    desirability: 
inland,    preferably    the    mountains    for    the 
entire  summer. 

3.  The  least  desirable:  the  seashore  for 
the  entire  summer. 

I  do  not  wish  it  understood  that  many 
children  will  not  do  well  at  the  seashore  if 
kept  there  the  entire  summer;  some,  indeed, 
improve  wonderfully;  but  among  my  own 
patients  I  have  been  repeatedly  impressed 
with  the  disadvantages  of  a  prolonged  outing 
by  the  sea.  The  seashore  children,  as  a  rule, 


Summer  Resorts  3 1 1 

do  not  return  to  the  city  in  the  fall  with  the 
vigor,  appetite,  and  general  robustness  which 
characterize  those  who  return  from  the 
mountains.  I  refer  only  to  New  York  chil- 
dren, whose  home  is  a  seaport,  and  who 
Jirive  best  when  given  the  advantage  of 
a  complete  change  to  the  dry,  invigorating 
air  of  the  mountains.  Children  with  catar- 
rhal  tendencies,  adenoids,  bronchitis,  and 
rheumatism,  and  those  convalescent  from 
pneumonia,  should  not  go  to  the  seashore. 

In  selecting  an  inland  resort,  the  moun- 
tains, by  which  we  understand  an  elevation 
of  from  fifteen  hundred  to  two  thousand 
feet,  are  not  always  necessary.  The  place 
selected,  however,  should  have  an  elevation 
of  at  least  six  hundred  feet,  and  should  not 
be  within  sixty  miles  of  the  coast.  Children 
who  are  subject  to  rheumatism  and  bron- 
chitis do  best  on  a  sandy  soil,  in  a  dry  cli- 
mate, with  the  sleeping  rooms  above  the 
ground  floor. 

Another  point  to  be  considered  in  this 
connection  is  the  kitchen  facilities  which 
will  be  provided  for  the  preparation  of  the 
child's  food.  As  a  rule,  the  larger  hotels 
refuse  the  right  of  way  to  the  kitchen;  or, 


3i2  Drug-Giving 

it"  they  do  not,  it  is  at  the  expense  of  many 
material  attentions  to  the  chef.  I  find  that 
mothers  arc  given  much  more  latitude  as 
to  these  matters  in  the  smaller  hotels  and 
hoarding-houses.  The  proper  preparation 
of  a  child's  food  in  the  cramped  quarters 
of  the  sleeping  apartment  is  not  impossible, 
hut  it  is  very  difficult. 

Before  selecting  a  summer  home,  the 
drainage,  the  milk,  and  the  water  supply 
must  be  considered.  If  the  parents  possess 
the  means,  a  cottage  should  be  rented,  which 
will  insure  them  all  the  comforts  of  home. 
Country  well  water  or  spring  water  should 
always  be  boiled  before  using. 

DRUG-GIVING 

Drugs  are  of  service  only  in  the  hands  of 
those  who  are  trained  in  their  use.  .Mothers 
often  acquire  the  habit  of  treating  their  chil- 
dren. Self-prescribing  is  greatly  overdone 
in  this  country  among  all  classes.  Many 
peoplr  know  just  enough  about  medicines 
to  be  dangerous  members  of  society.  The 
proprietary  cough  mixtures,  soothing  syrups, 
teas,  carminatives,  etc.,  are  often  injurious. 


The  Daily  Outing  313 

They  usually  contain  opium, — a  drug  which 
a  mother  should  never  think  of  giving  her 
baby  on  her  own  responsibility.  It  is  not 
at  all  uncommon  in  hospital  work  to  have 
children  admitted  in  an  opium  stupor  which 
resists  all  treatment  for  hours. 

While  the  habit  of  promiscuous  drug- 
giving  is  to  be  condemned,  the  mother  is 
not  supposed  to  remain  inactive  wrhile  await- 
ing the  arrival  of  the  physician ;  a  preliminary 
dose  of  castor-oil  in  diarrhoea,  or  syrup  of 
ipecac  in  croup,  or  rhubarb  and  soda  when 
there  is  a  furred  tongue  in  indigestion,  will 
always  be  in  order.  The  mother  may  have 
her  home  remedies,  but  the  physician  must 
instruct  her  in  their  use. 

THE  DAILY  OUTING 

The  baby  should  not  go  out  in  stormy 
weather.  If  under  one  year  of  age  he  should 
not  go  out  if  the  temperature  is  below  20° 
P.  During  the  midday  heat  of  summer  the 
baby  is  better  off  in  the  largest  and  coolest 
room  in  the  house  or  on  a  shady  ver- 
anda. On  very  windy  days  the  outing 
should  be  postponed.  When  the  snow  is 


Indoor  Airing 

melting  in  large  quantities  the  baby  is  better 
off  indoors. 

INDOOR  AIRING 

For  this  purpose  the  child  is  dressed  as 
for  the  daily  outing.  All  the  windows  of 
the  nursery  or  some  other  large  room  are 
opened,  on  one  side  of  the  room  only.  The 
doors  should  be  closed,  so  that  currents  of 
air  are  avoided.  The  child  is  placed  in  his 
carriage,  suitably  covered,  and  wheeled  about 
the  room  for  an  hour  or  two.  This,  if  done 
twice  daily,  answers  almost  as  well  as  the 
actual  outing. 

This  method  will  be  found  very  useful  in 
"winter  babies"- — those  born  during  the  late 
fall  or  winter  months.  The  indoor  airing 
may  be  given  for  a  week  or  more,  before  he 
is  taken  out.  By  this  means  the  child  is 
gradually  accustomed  to  a  change  of  the 
temperature  from  that  of  the  average  living- 
room  to  that  of  out-of-doors,  and  will  not 
be  harmed  when  he  is  finally  taken  out. 
After  an  illness,  it  will  afford  an  earlier  means 
of  returning  to  the  daily  outing.  This 
method  of  giving  a  child  fresh  air  will  be 


.    Children's  Parties  315 

found  useful  with  very  delicate  children, 
who,  by  reason  of  their  condition,  may  be 
unable  to  go  out  during  the  winter  months 
for  several  weeks  at  a  time.  There  are, 
however,  but  few  days  during  the  winter 
that  are  too  cold  or  too  stormy  for  the  indoor 
airing. 

CHILDREN'S  PARTIES 

Parties  for  children  under  the  sixth  year 
of  age  are  to  be  discouraged.  The  import- 
ant features  of  a  child's  party  are  entertain- 
ment and  the  "banquet."  There  are  two 
features  of  child  life  that  are  important  to 
guard  against — excitement  and  injudicious 
feeding.  Exciting  play  and  unusual  articles 
of  food  at  an  unusual  time  appear  to  be  a 
necessary  part  of  a  so-called  children's  party. 
The  bringing  together  of  children  of  tender 
age  is  further  to  be  discouraged  because  it 
increases  their  liability  to  contract  the  con- 
tagious diseases  from  which  every  child 
should  be  protected  to  the  full  extent  of 
our  ability. 

Xot  long  since  a  patient, — a  little  boy  four 
years  old, — invited  fourteen  little  boys  and 


316    Baskets  for  Early  Exercise 

girls  of  corresponding  ages  to  celebrate  his 
birthday.  The  little  host  was  more  gen- 
erous than  was  his  wont ;  he  gave  more  than 
the  banquet!  The  night  of  the  birthday 
party  he  was  very  uncomfortable.  The 
following  day  he  developed  chicken-pox.  In 
due  course  of  time  twelve  of  the  fourteen 
little  guests  came  down  with  chicken-pox. 
They  were  fortunate  that  it  was  only  chicken- 
pox;  it  might  have  been  scarlet  fever  or 
diphtheria. 

I  regret  that  I  have  not  kept  a  record 
of  the  acute  illnesses  that  have  followed 
children's  parties  under  my  immediate  ob- 
servation. Acute  indigestion,  diarrhoea,  con- 
vulsions, and  all  of  the  contagious  diseases 
of  childhood  would  be  found  in  generous 
numbers  in  such  a  record. 

BASKETS  FOR  EARLY  EXERCISE 

It  is  a  great  mistake  to  have  the  infant 
constantly  in  arms.  The  first  baity  suffers 
more  in  this  respect  than  later  children. 
When  the  child  is  held,  there  is  always  a 
tendency  to  make  him  sit  on  the  arm  or  knee 
without  proper  support,  or  to  toss  about  or 
handle  him  regardless  of  eonsef  juences.  The 


Baskets  for  Early  Exercise    317 

hones  and  ligaments  of  the  spinal  column 
are  not  sufficiently  developed  to  hear  the 
weight  of  the  heavy  head  and  trunk,  and, 


VIC,    19.       BASKET    FOR    EARLY    EXERCISE 

as  a  result,  as  the  child  grows  older,  spinal 
curvature  and  other  deformities  not  infre- 
quently follow.  By  urging  him  to  stand 
on  the  lap  the  legs  are  used  more  than  is 
advisable,  and  we  find  how-legs  or  knock- 
knees  very  prevalent. 

A  large  clothes-basket,  in  which  a  thick 
blanket  has  been  placed  (see  Pig.  19)  furnishes 
a  safe  and  satisfactory  playground.  For 
the  first  few  months  the  child  will  rest  on 
his  back  and  amuse  himself  in  his  own  pecu- 
liar way.  When  he  can  sit  up,  supported 
by  a  pillow  at  his  back,  the  basket  gives  him 


3i8  Night  Terrors 

plenty  of  room  for  toys  and  other  baby  re- 
quirements. In  it  the  baby  is  practically 
safe.  He  is  not  apt  to  be  injured  by  young 
members  of  the  family  in  rough  play.  He 
cannot  crawl  to  the  stove  to  be  burned,  and 
is  in  no  danger  of  rolling  down-stairs.  When 
he  can  stand  and  begins  to  walk,  the  basket 
period  is  at  an  end. 

NIGHT  TERRORS 

The  child  awakens  suddenly  from  sleep, 
cries  out  with  fear,  and  begs  to  be  protected 
from  men  and  animals,  which  he  imagines 
are  trying  to  injure  him.  In  some  cases 
the  nurse  and  immediate  relatives  of  the 
family  will  not  be  recognized.  The  seizures 
may  occur  quite  regularly  every  night  until 
the  cause  is  removed.  Other  children  may 
have  but  one  or  two  attacks  in  a  week.  The 
seizures  are  usually  due  to  a  disordered  diges- 
tive tract  in  a  nervous  child.  Adenoids  and 
enlarged  tonsils  are  considered  by  some  to 
act  as  a  predisposing  cause.  Anxiety  re- 
garding school  duties,  or  overwork  at  school 
may  help  to  bring  on  an  .attack;  worms  may 
also  be  a  cause.  My  cases  have  all  been  due 
cither  to  acule  or  chronic  digestive  disturb- 


Scales  for  Weighing          319 

ances  in  nervous  children.  A  boy  patient 
twelve  years  of  age  has  had  two  attacks 
every  year,  with  one  exception,  since  he  was 
six  years  old.  These  attacks  always  occur 
on  the  nights  after  Christmas  and  his  birth- 
day, after  indulgence  in  all  sorts  of  unsuitable 
articles  of  food. 

During  the  attack  the  child  must  be  treated 
with  gentleness;  scolding  makes  matters 
worse.  If  possible,  he  should  be  induced  to 
go  to  sleep ;  oftentimes  a  change  to  the  bed 
of  the  nurse  or  mother  for  the  remainder  of 
the  night  will  be  all  that  is  necessary;  or  a 
light  may  be  left  burning  in  the  room.  The 
attacks  may  usually  be  prevented  by  a  suit- 
able diet.  The  evening  meal  should  be  very 
light — a  cereal  with  milk  and  a  little  stewed 
fruit  is  sufficient.  This  light  supper  has 
relieved  several  of  my  patients  of  habitual 
night  terrors.  Constipation  is  often  an  im- 
portant factor,  and  when  present  requires 
treatment  before  relief  is  to  be  expected. 

SCALES  FOR  WEIGHING 

A  scale  for  weighing  the  baby  is  a  very 
necessary  adjunct  to  the  nursery  furnishings. 


,20          Scales  for  Wcighin 


There  are,  on  the  market,  several  varieties 
of  scales  for  weighing  the  baby,  which  arc 
unknown  as  "baby  scales."  The  usual  con- 
struction is  that  of  a  basket,  into  which  the 
baby  is  placed,  supported  by  a  rod  which 
rests  upon  a  spring.  A  needle  indicates  on 
a  dial  the  weight  of  the  child.  The  use  of 


rir,.  20.     scoop  AND   PLATFORM   SCALF.S  FOR  WF.IGUIM; 

these  scales  is  not  to  be  advised.  They  get 
out  of  order  easily,  are  expensive,  and  with 
a  vigorous,  kicking,  crying  baby,  the  rapid 
oscillations  of  the  needle  often  prevent  the 
weight  being  read  with  any  degree  of  accu- 
racy. Further,  their  weight  capacity  is  but 


The  Exercise  Pen  321 

twenty  pounds.  When  the  child's  weight 
reaches  this  figure,  it  necessitates  the  pur- 
chase of  other  scales.  The  scoop  and  plat- 
form scales  used  by  grocers  (see  Fig.  20) 
answer  the  purpose  far  better  than  any 
others.  They  can  be  bought  for  about 
S3-50,1  do  not  get  out  of  order,  and  weigh 
correctly  from  one-half  ounce  to  two  hun- 
dred and  eighty  pounds.  The  infant  rests 
on  his  back  in  the  scoop  during  the  weigh- 
ing process.  Older  children  stand  on  the 
platform. 

THE  EXERCISE  PEN 

In  a  previous  chapter,  in  speaking  of  cold 
and  how  children  were  exposed  to  influences 
which  might  bring  about  what  is  known  as  a 
"cold,"  the  custom  of  allowing  a  child  to  sit 
on  the  floor  is  referred  to. 

To  keep  a  child  from  eight  to  twenty-four 
months  of  age  off  the  floor  during  the  winter 
months,  and  thereby  prevent  his  taking  cold, 
is  a  very  difficult  matter.  In  fact,  with 
active  children  who  are  learning  to  walk, 

1  Metropolitan  Hardware  Co. .Church  and  Vesey  Sts., 
X.  V  C. 


The  Exercise  Pen  323 

or  who  have  just  learned  to  walk,  it  is  prac- 
tically impossible.  During  this  season  of  the 
year  there  is  always  a  current  of  cold  air  near 
the  floor,  and  allowing  the  child  to  creep  on 
the  floor  in  winter,  even  if  it  is  protected  by 
rug  and  pillows,  is  one  of  the  surest  ways  of 
taking  cold.  If  he  is  allowed  to  walk  on  the 
floor  he  is  very  sure  to  sit  in  a  very  few 
minutes.  If  he  is  not  allowed  to  creep  and 
walk  about  at  will  he  will  not  get  the  proper 
exercise,  and  will  show  faulty  development; 
for  such  cases  I  have  found  the  exercise  pen 
(see  Pig.  21)  of  immense  service.  After  being 
dressed,  washed,  and  fed,  the  infant  is  placed 
in  the  pen  on  a  rug  or  quilt,  toys  are  given 
him,  and  the  door  closed.  He  can  now  roam 
about  at  will,  stand  up,  sit  down,  roll,  creep, 
or  walk  without  danger  of  physical  harm 
from  rolling  down-stairs,  being  burned,  or 
being  stepped  on.  He  is  thus  given  an 
opportunity  for  active  exercise  without  a 
possible  chance  of  injury. 

A  young  mother  of  two  children  will  take 
her  "pen"  into  the  country  in  the  summer 
and  place  it  in  the  shade  for  use  while  the 
dew  is  on  the  grass.  In  case  the  nursery  is 
small  it  can  be  made  so  as  to  fit  over  the 


324  Food  Formulas 

nurse's  bed  and  consequently  does  not  re- 
quire any  additional  space.  In  a  large 
nursery  it  can  be  placed  permanently  in 
one  corner  of  the  room,  thus  avoiding  the 
trouble  of  putting  it  up  and  taking  it  down. 
The  pen  can  be  made  of  any  size, — 4  x  6  ft. 
is  probably  the  most  convenient,  although 
several  made  4x4  ft.  are  in  use.  It  is  so  con- 
structed as  to  be  taken  apart  and  put  to- 
gether in  a  few  moments,  iron  tenon  hooks 
and  iron  mortices  being  used  to  hold  the  parts 
together.  The  floor  may  be  made  of  any 
thin  material.  One-quarter  inch  pine  boards 
nailed  together  so  that  the  floor  will  be  com- 
posed of  two  thicknesses,  or  papier-mache 
supported  by  narrow  strips  of  board,  may 
be  used.  The  floor  is  supported  by  strips 
of  board  about  one-half  by  two  inches,  which 
arc  fastened  to  the  inner  side  of  the  end- 
pieces. 

FOOD  FORMULAS 

Beef -juice. — Take  a  round  steak,  cut  into 
pieces  the  size  of  a  horse-chestnut,  place  in 
a  buttered  pan  in  a  hot  oven,  and  bake  for 
fifteen  minutes;  remove  from  the  pan  and 


Food  Formulas  325 

press  out  the  blood  with  a  lemon-squeezer 
or  meat-press.  Or,  broil  round  steak  very 
rare,  cut  into  small  pieces,  place  in  a  lemon- 
squeezer  or  meat-press,  and  press  out  the 
blood ;  add  a  little  salt. 

Beef,  mutton,  and  chicken  broth. — Take  one 
pound  of  meat  free  from  fat,  cook  for  three 
hours  in  one  quart  of  water,  adding  water 
from  time  to  time,  so  that  when  the  cooking 
is  completed  there  will  be  one  pint  of  broth. 
When  the  broth  is  cool,  remove  the  fat, 
strain  and  add  salt. 

Scraped  beef. — Broil  round  steak  slightly 
over  a  brisk  fire.  Split  the  steak  and  scrape 
out  pulp,  using  a  dull  knife. 

Egg-water. — The  white  of  one  egg,  thor- 
oughly beaten  in  one  pint  of  cold  boiled 
water,  strain,  add  a  pinch  of  salt. 

Oatmeal  jelly. — Oatmeal,  four  ounces; 
water,  one  pint;  boil  for  three  hours  in  a 
double  boiler,  water  being  added,  so  that 
when  the  cooking  is  completed  a  thin  paste 
will  be  formed.  This  while  hot  is  forced 
through  a  colander  to  remove  the  coarser 
particles.  When  cold,  a  semi-solid  mass  will 
be  formed. 

Wheat  jelly  and  barley  jelly. — Wheat  jelly 


326  Food  Formulas 

and  barley  jelly  are  made  in  the  same  way 
as  oatmeal  jelly,  using  cracked  wheat  or 
barley  grains. 

Barley-water. — Robinson's  barley  flour  or 
Cereo  Co.'s  barley  flour,  one  rounded  table- 
spoonful  ;  water,  one  pint ;  boil  thirty 
minutes,  strain,  add  water  to  make  one  pint. 

Rice-water. — Rice,  one  tablespoonful ; 
water,  one  pint;  boil  three  hours,  adding 
water  from  time  to  time,  so  that  there  is 
one  pint  of  rice-water  at  the  end  of  three 
hours. 

Dextrinized  barley-water. — Robinson's  bar- 
ley flour  or  Cereo  barley  flour,  three  table- 
spoonfuls;  water,  one  pint;  boil  twenty 
minutes,  add  water  to  make  a  pint.  When 
lukewarm  (100°  F.)  add  one  teaspoonful  of 
Cereo,  strain;  this  changes  the  starch  into 
dextrinized  maltose. 

Oatmeal-water. — Oatmeal,  one  tablespoon- 
ful ;  water,  one  pint ;  cook  three  hours  and 
add  water  to  make  one  pint. 

Imperial  grammi-watcr. — Imperial  granum, 
one  tablespoonful;  water,  one  pint;  cook 
thirty  minutes  and  add  water  to  make  one 
pint. 

Whey. — Put  one  pint  of  fresh  milk  into  a 


Food  Formulas  327 

saucepan  and  heat  it  lukewarm,  not  over 
100°  F. ;  then  add  two  (2)  teaspoonfuls  of 
Fairchild's  essence  of  pepsin  and  stir  just 
enough  to  mix.  Let  it  stand  until  firmly 
jellied,  then  beat  with  a  fork  until  it  is  finely 
divided,  strain,  and  the  whey,  the  liquid 
part,  is  ready  for  use. 

Junket. — To  one  pint  of  fresh  milk  add 
one  tablespoonful  of  essence  of  pepsin  or  a 
junket  tablet,  and  two  teaspoonfuls  of  sugar. 
Allow  it  to  stand  over  a  fire  until  the  tem- 
perature is  100°  F. ;  then  add  vanilla  as  a 
flavoring  and  allow  it  to  stand  until  the  curd 
is  set,  when  it  should  be  placed  upon  ice. 


THE    END 


Q 


This  book  is  DUE  on  the  last  date  stamped  below 


I/I.  ^ 

W  23 
°CT  5     193^ 

JUN  6     1945 
MV241S50' 


Form  L-O-l 


1AL  LIBRARY  FACILITY 


A    001378533    2 


PJ 


u 


